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ISTRY 


in the 

United States of America 


A collection of articles reprinted with permission, from The Journal of The American Dental Association, 
The Military Surgeon and Annals of Dentistry, by The United States Office of War Information, 1945 


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TABLE OF CONTENTS 

I. PREVENTIVE DENTISTRY 

USE OF FLUORINE IN THE PREVENTION OF DENTAL CARIES . 

I. Rationale and Approach — Basil G. Bibby, D.D.S., Ph.D., Boston, Mass. 

The Journal of the American Dental Association, Vol. 31, No. 3, February 1, 1944. 

THE USE OF FLUORINE IN THE PREVENTION OF DENTAL CARIES ... 

II. Effect of Sodium Fluoride Applications — B. G. Bibby, B.D.S., Ph D., D.M.D., Boston, Mass. 
The Journal of the American Dental Association, Vol. 31, No. 5, March 1, 1944. 

RAMPANT DENTAL CARIES: PREVENTION AND PROGNOSIS . 

A Five Year Clinical Survey - Hermann Becks, M.D., D.D.S.; Arthur L. Jensen, D.D.S., 
and Compton B. Millar, D.D.S., San Francisco, Calif. 

The Journal of the American Dental Association, Vol. 31, No. 17, September 1, 1944. 

GINGIVITIS AND VITAMIN C. 

J. S. Restarski, M.D.S., D.D.S., and M. Pijoan, B.A., M.D., Bethesda, Md. 

The Journal of the American Dental Association, Vol. 31, No. 19, October 1, 1944. 


II. PROTECTIVE DENTISTRY 

THE LOCAL USE OF SULFANILAMIDE AND SULFATHIAZOLE IN EXTRACTION WOUNDS... 

A Preliminary Report — First Lieutenant Leonard Weiner, A.B., D.M.D., Dental Reserve 
The Military Surgeon, Vol. 90, No. 2, February, 1942. 


LOCAL USE OF SULFANILAMIDE AND SULFATHI AZOLE IN EXTRACTION WOUNDS 

Leonard Weiner, A.B., D.M.D., Tucson, Arizona. 

The Journal of the American Dental Association, Vol. 31, No. 19, October 1, 1944. 


USE OF VINETHENE AS AN ADJUNCT IN NITROUS OXIDE-OXYGEN ANESTHESIA FOR 
DENTAL SURGERY . 

Neal W. Chilton, B.S., D.D.S., New York, N. Y. 

The Journal of the American Dental Association, Vol. 31, No. 7, April 1, 1944. 


PHYSICS AND MECHANICS INVOLVED IN SERVICEABLE PORCELAIN JACKET CROWN 
RESTORATIONS.. 

Loren D. Sayre, D.D.S., M.S.D., Chicago, Ill. 

The Journal of the American Dental Association, Vol. 31, No. 1, January 1, 1944. 


A NEW TYPE OF PORCELAIN BRIDGE AND THE TECHNIC FOR ITS CONSTRUCTION 

Arthur F. Schopper, D.D.S., Kansas City, Mo., and Jacob A. Saffir, D.D.S. Kew Gardens, L. I., N. Y. 

The Journal of the American Dental Association, Vol. 31, No. 19, October 1, 1944. 


COMPLETE DENTURE IMPRESSIONS BASED UPON THE ANATOMY OF THE MOUTH 

Carl O. Boucher, D.D.S., Columbus, Ohio. 

The Journal of the American Dental Association, Vol. 31, No. 17, September 1, 1944. 

A PRELIMINARY REPORT ON PENICILLIN IN DENTISTRY . 

Leo Stern, D.D.S., 

Annals of Dentistry, Vol. 3, No. 1, June 1944. 


ROOT-CANAL THERAPY AND THE USE OF SULFONAMIDES 

Norman Rosen, D.M.D., New York, N. Y. 

The Journal of the American Dental Association, Vol. 31, No. 9, May 1, 1944‘. 

TRANSFER 


17 

-\:JUN & 1945 

( 'EeriaJ Hdcord Of vision 
Library o? Confirm 














I. PREVENTIVE DENTISTRY 


USE OF FLUORINE IN THE PREVENTION OF 

DENTAL CARIES 

I. RATIONALE AND APPROACH 


Basil G. Bibby, D.D.S., Ph.D., Boston, Mass. 


M OST of the outstandingly success¬ 
ful methods of preventing disease 
are those which have had their 
origins in naturally occurring phenomena 
of immunity. Vaccination against small¬ 
pox, for instance, is a direct outgrowth 
of the observation that this disease was 
prevented by infection with cowpox. 
Immunization against diphtheria is, in a 
less direct way, an example of the same 
sort; but, with this disease, practical 
prophylactic methods could not be estab¬ 
lished until exact theoretical explanations 
of the basic reactions between toxin and 
antitoxin had been worked out. 

The story of malaria, pellagra, rickets 
and many other diseases furnishes further 
examples of practical methods of control 
which have resulted from the working 
out of causal relationships from the study 
of naturally occurring phenomena of 
susceptibility or resistance. Indeed, it is 
seldom that prophylactic procedures can 
be brought to a practical state without 
a thorough understanding of the under¬ 
lying mechanisms responsible for the 

From the Division of Preventive Dentistry 
and Department of Pathology and Bacteriol¬ 
ogy, Tufts College Dental School. 

Jour. A.D.A., Vol. 31, February 1, 1944 


natural immunity. Three steps can gen¬ 
erally be recognized in such a develop¬ 
ment : ( 1 ) studies on epidemiology and 
the phenomena of natural resistance ; ( 2 ) 
discovery of the mechanism by which this 
resistance is brought about, and ( 3 ) the 
working out of methods of utilizing these 
mechanisms for preventing disease in 
otherwise susceptible groups. Apparently, 
this step by step approach has never been 
fully recognized or conscientiously fol¬ 
lowed in attempts to work out methods 
for the control of dental disease. In re¬ 
cent years, sufficient epidemiologic and 
other evidence has accumulated on the 
subject of the relationship of fluorine to 
dental caries to make it profitable to 
follow the approach outlined above in 
considering the possibility of preventing 
caries by some type of fluorine therapy. 
The remainder of this paper is devoted 
to such an analysis of our knowledge of 
the relationship of fluorine to dental 
caries. 

PHENOMENA OF CARIES RESISTANCE IN 
RELATION TO FLUORINE 

The findings in (a) epidemiologic 
studies, (b) chemical studies and (c) 


2 










animal experiments demonstrate convinc¬ 
ingly that fluorine acts in some way to 
prevent dental decay. 

Epidemiologic Studies .—For many 
years, evidence has been accumulating 
which suggested that, in addition to caus¬ 
ing mottling of enamel, fluorine in drink¬ 
ing water also contributed in some way to 
a reduction of caries. In a series of pub¬ 
lications, Dean and his associates have 
demonstrated that amounts of fluorine 
below those which cause mottling of 
enamel would cause a marked reduction 
in caries activity. The most recent re¬ 
port, 1 which summarizes many of the 
previous studies, shows that, in twenty- 
one cities, there was an inverse relation¬ 
ship between the fluorine content of 
drinking water and the amount of dental 
caries. Children in cities with one part 
per million or more of fluorine in the 
water had only one-third to one-half the 
caries that children had in cities having 
a fluorine content of less than 0.5 part 
per million in the water. It is particu¬ 
larly interesting that this report shows 
a reduction in caries much more marked 
in the upper incisors than in other teeth. 
Communities with fluorine levels above 
0.6 part per million had only one-nine¬ 
teenth of the amount of incisal caries 
that was present in those using waters 
with less than 0.5 part per million. In 
the same groups, the reduction of decay 
in the molars was only one quarter of 
that in the incisors. This marked effect 
on the incisor caries accounts adequately 
for Arnim, Aberle and Putney’s 2 failure 
to find a single carious incisor in a thou¬ 
sand Indians examined in an area of 
endemic fluorosis and, as will be pointed 
out later, casts light on the mechanism 
of fluorine action. The low occurrence 
of dental caries in association with fluo¬ 
rine in drinking water is now a well- 
recognized clinical phenomenon, noted 
in many parts of the world. Sognnaes’ 
report 3 of the dental conditions in Tris¬ 
tan da Cunha is the only one of a situa¬ 
tion in which a high fluorine content in 


the food (contained in fish, which was 
the principal item in the diet) has acted 
to prevent caries. 

Chemical Studies .—It has been shown 
that caries-resistant teeth have a higher 
fluorine content than do caries-suscepti¬ 
ble teeth. Armstrong’s figures 4 for caries- 
resistant teeth are: enamel, o.om mg., 
and dentin, 0.0169 P er hundred 

cubic centimeters; and for caries-suscep¬ 
tible teeth: enamel, 0.0069 mg., and 
dentin, 0.0158 mg., per hundred cubic 
centimeters. In view of ideas to be 
developed later in this paper, it is im¬ 
portant to note that the principal in¬ 
crease of fluorine in the caries-free teeth 
was in the enamel and that the increase 
in the fluorine content of the dentin was 
negligible. 

Animal Experiments .—Although ex¬ 
perimental caries in rats bears only a 
slight resemblance to human dental de¬ 
cay, 5 it has, until recently, provided the 
only practical means of studying caries 
by animal experimentation. Obviously, 
because of the differences between this 
condition and human caries, conclusions 
from this source must be accepted with 
caution. Nevertheless, the demonstra¬ 
tion by a number of workers 6 ’ 7 that rat 
caries can be prevented by adding fluo¬ 
rides to the drinking water or food or by 
intra-oral administration even without 
ingestion 8 must be regarded as additional 
strong evidence that fluorine can pro¬ 
tect the teeth against caries. Other 
studies on rat caries, which will be re¬ 
ferred to later, have contributed to an 
understanding of the mechanism by 
which fluorine prevents decay. 

The foregoing summary of the findings 
in three different fields of scientific studv 

j 

shows clearly that fluorine acts in some 
way to prevent caries in man, and that, 
as a result of this action, a natural re¬ 
sistance to caries occurs in large popula¬ 
tion groups. Thus, dentistry is presented 
with a phenomenon of naturally occur¬ 
ring disease resistance and is given an 
opportunity to interpret this phenomenon 


3 



so that it can be turned into an effective 
and practical method of caries prophy¬ 
laxis. 

MECHANISM BY WHICH FLUORINE 
PREVENTS DENTAL CARIES 

In considering the possible ways by 
which fluorine could prevent or limit the 
progress of dental caries, one has to 
recognize the views both of those who 
believe that caries is the result primarily 
of systemic conditions and of those who 
believe that changes on the tooth surface 
are all-important. These possibilities can 
be adequately dealt yvith by considering, 
under three heads, the different mechan¬ 
isms so far suggested for the action of 
fluorine: (i) that the systemic effects 
of fluorine on the erupted or unerupted 
teeth bring about changes which in¬ 
crease their resistance to caries; (2) that 
fluorine acts through the saliva to add 
to the resistance of the teeth or weaken 
the attack of caries, and (3) that fluorine 
influences the mechanism of acid pro¬ 
duction and tooth decalcification at the 
tooth surface. 

The Systemic Effects of Fluorine .— 
Unerupted teeth: Early studies 9 on rats 
indicated that animals fed a high fluoride 
diet before the teeth erupted were less 
susceptible to “experimental caries” than 
rats not receiving a fluoride supplement. 
It was inferred from this that caries 
resistance in man was also the result of 
preeruptive changes in the teeth brought 
about by ingestion of fluorine. There 
are two reasons for questioning this con¬ 
clusion : First, as has already been 
pointed out, “experimental caries” in rats 
is not completely comparable to human 
caries and the findings have only a lim¬ 
ited significance for man. Second, similar 
studies 10 have had contradictory results. 
An indication that fluorine taken during 
tooth formation may influence caries 
activity in human beings can be found 
in Dean’s observation 11 of an apparent 
added resistance to decay in children of 
Bauxite who had used fluorine-contain¬ 


ing water only during the early years of 
life. The extent of caries reduction re¬ 
sulting from use of fluorides during the 
first eight years of life (which must of 
necessity include posteruptivc effects on 
certain teeth) is apparently less than half 
of that resulting from use extending into 
adult life. 12 That factors operating after 
tooth formation are more important than 
those operating during that period is sug¬ 
gested by the fact that caries reduction 
in the first permanent molars is only 
about one quarter of what it is in the 
incisors 1 despite the fact that the two 
types of teeth are formed at the same 
time of life. 

Erupted Teeth .—Because enamel and 
dentin are almost completely inert tis¬ 
sues, it seems unlikely that caries is pre¬ 
vented by metabolic effects of fluorine 
on the teeth. However, since there is 
accurate experimental evidence, 13 ob¬ 
tained by the use of radio-active isotopes, 
that phosphorus turnover in the enamel 
is as much as 10 per cent of that in the 
dentin and 2 per cent of that in the al¬ 
veolar bone, the possibility of some low- 
grade metabolic influence must be ad¬ 
mitted. Animal experiments 14 have shown 
that some radio-active fluorine enters the 
teeth from the blood stream or saliva, 
but, in addition, they have demonstrated 
that this element is not concentrated in 
either the enamel or the dentin in the 
same way that it is in the bone. Further, 
because the bulk of ingested fluorine is 
rapidly excreted in the urine, 14 the 
amount reaching the teeth is certainly 
minute enough to have very doubtful 
significance. This is particularly true 
when it is recalled that the fluorine 
would have to be concentrated in the 
enamel if the distribution of fluorine 
associated with caries resistance in man 4 
were to obtain. There is evidence 5 that 
this does not occur when fluorine is fed 
to animals. On the other hand, such 
administration of fluorine to rats does 
increase the fluorine content of the den¬ 
tin. 15 (The reduced occurrence of “ex- 


4 



perimental caries” in rats associated with 
this fluorine increase in the dentin is 
almost certainly explicable on the basis 
of the difference between “experimental 
caries” and human caries. 5 ) 

Salivary Effects of Fluorine. —Because 
it is in continuous contact with the tooth 
surfaces and because it may reflect sys¬ 
temic conditions, the saliva has to be con¬ 
sidered as a possible intermediary agent 
in the action of fluorine. Studies with 
partially desalivated rats led Cheyne 16 to 
conclude “that saliva is of vast im¬ 
portance especially as it acts to transport 
the caries-inhibitory factor.” However, 
in a reinterpretation of the same experi¬ 
ments, 17 he abandoned this opinion. 
Sognnaes expanded the same experimen¬ 
tal approach, using local applications 8 
and stomach tube administration of fluo¬ 
rides, and was able to demonstrate that 
the presence or absence of salivary glands 
did not influence the progress of caries 
in rats, thus indicating that the saliva 
was not the instrument by which either 
local or systemic effects of fluorine were 
brought about. A further indication that 
saliva is unimportant is found in studies 
with radio-active fluorine 14 ’ 19 which re¬ 
vealed that great increases of fluorine in 
the blood do not significantly change 
the fluorine content of the saliva. The 
absence of differences between the fluo¬ 
rine content of saliva of children using 
fluoride-containing water (low caries) 
and children using fluorine-free water 
(high caries) supports this conclusion. 20 
Finally, the most striking evidence that 
saliva is of no importance in bringing 
about fluorine resistance to caries is found 
in the previously recorded clinical stud¬ 
ies 1 that fluorine is four times as effective 
in reducing caries in the upper incisor 
teeth, where salivary influences are at a 
minimum, as in the molars where this 
effect is maximal. When considered to¬ 
gether, these findings establish definitely 
that caries reduction by fluorine is 
brought about without the intermediary 
action of saliva. 


3. Effects of Fluorine on Acid Produc¬ 
tion and Acid Resistance of Teeth. —Re¬ 
cent studies 21 on various aspects of den¬ 
tal caries have greatly strengthened the 
idea that this disease is primarily the 
result of the destruction of enamel and 
then dentin by the action of locally 
formed acids. It is conceded that a va¬ 
riety of local and systemic conditions 
modify the speed of tooth destruction, 
but as yet no mechanism for tooth de¬ 
struction other than the action of acid 
has been demonstrated. Consequently, 
considerations of local factors in caries 
must deal mainly with the effects of fluo¬ 
rine on the formation of acids, and its 
possible influence on the resistance of 
enamel and dentin to acids. A fuller 
discussion of these questions has been 
presented elsewhere. 22 

Acid formation : Since the formation 
of acids in the mouth is the result of 
decomposition of carbohydrates, it is 
necessary to consider the effects of fluo¬ 
rine on this process. There is no reason 
to believe that fluorine interferes with 
the breakdown of starches to sugar. In¬ 
deed, McClure 23 has shown that concen¬ 
trations of fluorine such as might be met 
with in the mouth cause no limitation of 
diastatic activity, and that the saliva of 
children using water with 1.8 parts per 
million of fluorine does not differ in its 
ability to break down starch from that 
of children using fluorine-free water. 
There is, however, much evidence 24 that 
fluorine can interfere with the later and 
more important phase of carbohydrate 
breakdown, the formation of acids from 
sugar. Fluorine contained in fluorosed 
teeth has a kindred effect. It is possible, 
therefore, that this action of fluorine 
may contribute toward a reduction in 
the activity of caries. 

Tooth resistance: Fluorine might 
add to the resistance of the teeth by 
acting in some way to increase the 
capacity of the teeth to repair them¬ 
selves. Laboratory and clinical evidence 
that this type of reaction does not 


5 


occur has been offered earlier in this 
paper. 

Again, incorporation of fluorine in the 
teeth, regardless of its manner of ac¬ 
quisition, might add to their ability to 
withstand the action of mouth acids. 
That this is very likely is suggested by 
the action of fluorine in reducing the 
solubility of rock phosphate. 25 That a 
similar effect is actually brought about 
on the teeth by fluorine was demon¬ 
strated by Volker. 26 When this is con¬ 
sidered, in conjunction with the findings 4 
that human teeth with a high fluorine 
content in the enamel are more resistant 
to decay than those with less fluorine, 
we have the strongest kind of evidence 
hat the caries resistance associated with 
fluorine is primarily the result of an in¬ 
creased content of this element in the 
dental enamel. Of all the possibilities 
considered, this seems to be the only one 
which adequately explains all of the clin¬ 
ical and laboratory findings. The in¬ 
creased fluorine in the teeth could delav 
caries either by adding to their acid re¬ 
sistance or, to a lesser extent, by limiting 
acid production in the immediate vicinity 
of the enamel. 24 We must conclude, 
then, that this is the principal way in 
which fluorine acts to reduce dental 
caries. 

Manner of Acquisition of Fluorine by 
the Teeth .—Since the evidence offered 
so far indicates that salivary action and 
preemptive or systemic influences on the 
teeth are relatively unimportant in in¬ 
fluencing fluorine resistance to caries, the 
conclusion just reached is essentially a 
negative one, unless an explanation of 
how the fluorine reaches the enamel is 
provided. Fortunately, a satisfactory 
answer can be supplied. 

For some time, there has been evi¬ 
dence in the literature that bone com¬ 
bined actively with fluorides. Half a 
century ago, Carnot 27 demonstrated that 
the fluorine content of bone was' in¬ 
creased by immersing it in fluoride solu¬ 
tions. This reaction between fluorides 


and bone phosphates is apparently a very 
active one because contact with bone 28 
or hydroxylapatite 29 will remove fluorine 
from drinking water. That the chemi¬ 
cally similar phosphates of tooth enamel 
and dentin react similarly was demon¬ 
strated by Volker, who, using radio-active 
isotopes and solubility tests, showed that 
a short exposure of enamel and dentin 
to fluoride solutions resulted in a rapid 
reaction with fluorine, 30 causing a 
marked reduction in their solubility in 
acid. 31 Recently, this key finding that 
fluorine combines actively with the teeth 
has been confirmed by chemical analysis 
of teeth immersed for short periods of 
time in sodium fluoride solutions 32 or 
brushed with fiuorapatitc. 33 From this 
evidence, it may be concluded that a 
lowered acid-solubility of the teeth re¬ 
sults from an increased fluorine content 
of the Qnamel and dentin, which is 
brought about principally by a direct re¬ 
action between the fluorine of fluorine- 
containing water and the tooth enamel, 
independently of the ingestion of fluorine 
or its absorption into the system. Addi¬ 
tional support for this conclusion can be 
found in the experiments of Perry and 
Armstrong 34 and Sognnaes. 8 The former 
showed that increases in the fluorine con¬ 
tent of the enamel of rats’ teeth resulted 
from direct contact between the teeth 
and fluoride-containing drinking water 
and not from passage of the fluorine into 
the system. The latter demonstrated 
that caries in rats could be prevented by 
direct applications of fluorides to the 
teeth even when none of the fluoride was 
swallowed. 

This explanation of the mode of ac¬ 
tion of fluorine is in complete accord 
with clinical findings. If a direct com¬ 
bination takes place between the fluorine 
of the water and the tooth enamel, the 
degree of protection accorded to the 
different teeth should be proportionate 
to the extent of their contact with the 
water. Thus, the upper anterior teeth 
which come in greatest contact with the 


6 



fluoride-containing water during the act 
of drinking should be most benefited, 
whereas other teeth, such as the molars, 
which have less contact with the water, 
should show less caries reduction. The 
clinical studies 1 quoted at the beginning 
•of this paper show that this is the case, 
the reduction of caries in the upper an¬ 
terior teeth being more than four times 
greater than that in the molars. 

Conclusion .—The contents of the fore¬ 
going section can be briefly summarized 
by stating that attempts to explain the 
action of fluorine in preventing dental 
caries on the basis of its effects on tooth 
formation, tooth metabolism or salivary 
action were unsuccessful, but that a sat¬ 
isfactory explanation, which is supported 
by all existing laboratory and clinical * 
evidence, is provided by postulating that 
the increased resistance to caries is the 
result of a direct acquisition of fluorine 
by the tooth enamel from fluorine-con¬ 
taining waters or foods. This is appar¬ 
ently the result of a peculiar affinity 
which exists between calcium phosphates 
of the sort occurring in bones and teeth 
and fluorine, which results in a rapid 
reaction between fluorides of the water 
and the teeth. When fluorine combines 
with enamel or dentin, it greatly reduces 
their solubility in acid. This increased 
resistance to the action of acid is 
probably the primary cause for the 
reduction of caries in teeth which have 
come in contact with fluoride-containing 
waters. 

UTILIZATION OF FLUORINE IN THE 
PREVENTION OF DENTAL CARIES 

It seems that the simplest and most 
direct approach to the use of fluorine to 
reduce caries would be an increase of the 
fluorine content of the water supplies 
in caries-susceptible areas so that it 
would be the same as that of communi¬ 
ties with little decay. If there were no 
complicating factors, which there almost 
certainly would be, this could be ac¬ 
complished by adding fluorides to the 


water to bring about a fluorine content 
of one part per million. Such concen¬ 
trations of fluorine should reduce caries 
activity without causing mottling of the 
enamel. The use of fluorine supplements 
in water supplies has been advocated by 
Cox 35 as a means of combating dental 
decay. Experimental tests of this pro¬ 
cedure are under consideration at this 
time. 

One disadvantage of adding fluorine 
to the water supply is that there is rea¬ 
son 36 to believe that a fluorine supple¬ 
ment in a soft water would be absorbed 
to a different extent from that present 
when the same supplement was added to 
hard water or occurred naturally. Fur¬ 
ther, individual variations in water con¬ 
sumption, diet or metabolism would 
probably produce uneven results in dif¬ 
ferent children. These factors make it 
difficult to establish a universally satis¬ 
factory level of fluorine intake which 
will confer the advantages of caries pre¬ 
vention without the risk of producing 
mottling of the enamel or other as yet 
unknown undesirable effects which may- 
result from continuous ingestion of fluo¬ 
rine. Another disadvantage of this ap¬ 
proach is that the greatest caries reduc¬ 
tion which could be expected to result 
from using drinking water containing i 
part per million of fluorine, a concentra¬ 
tion which produces sporadic mild mot¬ 
tling of enamel, would be no greater than 
the approximately 50 per cent reduction 
shown to result 1 when like concentrations 
of fluorine occur naturally in the water. 
A reduction of caries to one-half is, of 
course, no more the desideratum than 
the direct infection with cowpox was the 
ultimate achievement in the prevention 
of smallpox. The aim in programs of 
caries prophylaxis should be to reduce 
caries in all teeth at least to the extent to 
which fluorine reduces decay in the an¬ 
terior teeth; namely, by from 90 to 95 
per cent of its normal incidence. 1 To 
accomplish this, it seems obvious that 
more refined methods of use than simple 


7 



addition to the drinking water must be 
worked out. 

In consideration of the mode of action 
of fluorine, it was concluded that the 
anterior teeth showed their phenomenal 
resistance to caries because they alone 
came into repeated direct contact with 
fluorine-containing water- Therefore, be¬ 
cause the reaction between fluorine and 
the enamel is a very rapid one, it seems 
likely that direct applications of fluorine- 
containing fluids to the teeth would re¬ 
duce caries. Moreover, if our conclusion 
on the mode of action of fluorine is cor¬ 
rect, the extent of the reduction should 
be approximately equal in all teeth. 

This possibility has recently been 
tested in a clinical study in Brockton. 3 ’’ 
38 Three times a year for two years, 
applications of 1/1,000 sodium fluoride 
were made to the teeth of one of the four 
quadrants of the jaws of a group of ioo 
children, and the progress of caries was 
compared with that in the opposite (con¬ 
trol) quadrant of the same jaw. Re¬ 
examination at the end of the first and 
second year showed a striking reduction 
of caries in the treated quadrants. In 
the test quadrants of eighty patients 
completing two years of treatment, 
eighty^three new cavities appeared; 
whereas, the corresponding untreated 
control quadrants in the same jaw, but 
other side of the mouth, there were 124 
new cavities. There was less difference 
in questionable caries (fillings, question¬ 
able caries and cavity enlargements), the 
test and control figures being 90 and 115. 
The reduction of caries in the molars 
(40 per cent) and bicuspids (33 per 
cent) was essentially the same as in the 
anterior teeth (34 per cent). 

These results, which have received 
confirmation in a more limited study, 34 
not only prove the correctness of our 
general conclusion regarding the mode 
of action of fluorine and the accuracy 
of our explanation of the different de¬ 
grees of caries reduction in incisors and 
molars when fluorine is taken in the 


drinking water, but also show that appli¬ 
cation of fluorine directly to the teeth 
will reduce caries, even though it is not 
taken into the system. There is no reason 
to believe that the caries reduction 
brought about in our study represents 
the best result obtainable by this general 
method. Since contact with fluorides in 
the drinking water reduces caries in the 
anterior teeth by as much as 95 per cent, 1 
it is not unreasonable to expect that a 
similar reduction could be brought about 
in all teeth when improved methods of 
making local applications are worked 
out. 

It is possible that this end could be 
accomplished either by giving more fre¬ 
quent fluoride treatments or by increas¬ 
ing the reactivity of the fluorides. The 
former could be accomplished (a) by 
having dentists or dental hygienists give 
frequent treatments, or modified treat¬ 
ments, of the kind given in the Brockton 
experiment; (b) by having patients ap¬ 
ply fluoride-containing preparations to 
their own teeth as part of their regime 
of oral hygiene, or (c) by subjecting the 
teeth to a concentrated series of fluoride 
treatments during a period of a few days. 
All these methods are now being investi¬ 
gated in various parts of the country, and 
the relative effectiveness of each ap¬ 
proach should soon be known. We have 
been able to make some progress in the 
latter direction 40 and will report progress 
toward increasing the solubility reducing 
effects of fluorides in another paper. 

The foregoing represent only a few of 
the possible ways in which fluorides can 
be used to control caries. It is likely, for 
instance, that the reaction between fluo¬ 
rine and the teeth could be increased by 
means of electrophoresis, thereby bring¬ 
ing about a greater reduction in tooth 
solubility. It is also probable that a pro¬ 
longed contact of fluorides with the teeth 
and a resultant increase in the solubility- 
reducing effect could be brought about 
by incorporating fluorides in such ma¬ 
terials as celloidin, which would adhere 


8 


to the teeth for long periods of time. 
These represent only some of the meth¬ 
ods which could be used to bring about 
solubility-reducing effects on the teeth. 
Until these and other approaches have 
been thoroughly investigated, it will be 
too soon to conclude that it is impossible, 
by means of direct fluoride treatments of 
the teeth, to reduce caries in all teeth to 
the extent that fluoride impregnation 
from the drinking water reduces it in 
the anterior teeth. 

GENERAL SUMMARY AND CONCLUSIONS 

The thesis is advanced that the most 
profitable approach to disease prevention 
is through the study and interpretation of 
natural phenomena of disease resistance. 

Evidence from clinical studies, chemi¬ 
cal analyses of teeth and animal experi¬ 
mentation is quoted to show that a 
naturally occurring phenomenon of re¬ 
sistance to dental caries is associated 
with the action of fluorine. 

The evidence relating to the possible 
ways in which fluorine could act to pre¬ 
vent dental caries is examined. It is 
concluded that its action is principally 
the result of an increased fluorine con¬ 
tent of the tooth enamel which is not 
brought about by preemptive or subse¬ 
quent systemic effects on the tooth. This 
fluoride increment in the enamel makes 
the teeth less soluble in acids and may 
also exert a minor secondary effect by 
reducing acid production by bacteria in 
its immediate vicinity. 

On the basis of geologic data and lab¬ 
oratory experiments with teeth, it is 
shown that the enamel can acquire fluo¬ 
rine after the teeth are erupted through 
the medium of direct external contact 
with fluoride-containing waters. This is 
offered as the mechanism by which the 
teeth acquire fluorine and an added re¬ 
sistance to caries. 

From this conclusion, it is postulated 
that treatments of the teeth with fluoride- 
containing solutions would reduce dental 
caries. Clinical tests are quoted to show 


that caries can be reduced by at least 30 
per cent by such a procedure. 

In a discussion of possible methods of 
using fluoride therapy to prevent dental 
caries, it is concluded that the addition 
of fluorine to water supplies will prob¬ 
ably yield a smaller reduction in dental 
caries than it will ultimately be possible 
to bring about by refinement of the gen¬ 
eral method of direct application of 
fluoride to the teeth. 

CONCLUDING COMMENT 

The work of establishing the influence 
of fluorine in controlling dental caries 
which has been summarized in this paper 
may well come to be recognized as the 
most important series of investigations in 
the recorded history of dentistry. 
Whether this turns out to be the case or 
not will depend on the course of research 
on the subject in future years. At worst, 
attempts to produce a significant reduc¬ 
tion of caries by practical measures of 
fluorine therapy may fail or produce un¬ 
desirable results of an unpredictable sort. 
Disappointment or reaction might then 
lead to a premature abandonment of this 
approach to caries control. At best, a 
number of effective ways of controlling 
caries by fluorine therapy may be worked 
out; or information obtained from such 
studies may lead to effective chemical 
therapy by agents other than fluorides. 

Since it is unlikely that even at its most 
effective level fluorine therapy will en¬ 
tirely prevent tooth decay, other ap¬ 
proaches to caries prevention should be 
continuously explored. Progress toward 
prevention can undoubtedly be made by 
furthering our knowledge of the effects 
of selection of carbohydrates which do 
not readily undergo fermentation, or 
which are rapidly eliminated from the 
mouth. Initial work in these fields gives 
great promise and, if fully exploited, 
might provide successful methods of 
caries prevention. The immediate possi¬ 
bilities for the control of caries are ex¬ 
tremely bright. .It is more than likely 


9 


that, in the near future, really effective 
procedures for caries prevention will be 
available, methods which will make such 
low. demands on time and money that 
they will be attractive and profitable for 
patients, dentists and public health or¬ 
ganizations alike. That such possibilities 
are now within our reach should serve 
as a challenge to all who are able to 
carry out or support work in the field of 
dental caries or public health. 

BIBLIOGRAPHY 

i. Dean, H. T.; Arnold, F. A., and 
Evolve, Edna: Pub. Health Rep., 57 :1155, 
August 7, 1942. 

. 2 . Arnim, S. S.; Aberle, S. D., and Put¬ 
ney, E. H.: Study of Dental Changes in 
Group of Pueblo Indian Children. J.A.D.A., 
24:478, March 1937. 

3. Sognnaes, R. F.: J. D. Res., 20:303, 
August 1941. 

4. Armstrong, W. D., and Brekhus, P. J.: 
J. D. Res., 17:393, October 1938. 

5. Bibby, B. G., and Sedwick, H. J.: J. D. 
Res., 13:429, December 1933. 

6. Miller, B. F.: Proc. Soc. Exper. Biol. & 
Med., 39:389, November 1938. 

7. Dodge, H. C.,‘ and Finn, S. B.: Proc. 
Soc. Exper. Biol. & Med., 42:318, October 
1939 - 

8. Sognnaes, R. F.: Brit. D. J., 70:433, 
June 16, 1941. 

9. Cox, G. J., et al.: J. D. Res., 18:481, 
December 1939. 

10. Cheyne, V. D.: Thesis, University of 
Rochester, 1940. 

11. Dean, H. T., et al.: Pub. Health Rep., 
56:365, February 28, 1941. 

12. Deatherage, C. F.: ]. D. Res., 22.129, 
April 1943. 

13. Volker, J. F., and Sognnaes, R. F.: 
J. D. Res., 20:471, October 1941. 

14. Volker, J. F.; Sognnaes, R. F., and 
Bibby, B. G.: Am. J. Physiol., 132:707, April 
1941. 

15. McClure, F. J.: J. D. Res., 22:37, 
February 1943. 

16. Cheyne, V. D.: J. D. Res., 19:28o, 
June 1940. 


17. Idem: Proc. Soc. Exper. Biol. & Med., 
43:58, January 1940. 

18. Sognnaes, R. F.: J. D. Res., 19:287, 
June 1940. 

19. Wills, J. H.: J. D. Res., 19:585, De¬ 
cember 1940. 

20. McClure, F. J.: J. D. Res., 20:283, 
June 1941. 

21. Bibby, B. G.: Dental Caries. Proc. Bi¬ 
centennial Cong., Univ. of Pennsylvania, 

1940. 

22. Volker, J. F., and Bibby, B. G.: Med¬ 
icine, 20:2ii, May 1941. 

23. McClure, F. J.: Pub. Health Rep., 54 : 
2165, December 8, 1939. 

24. Bibby, B. G., and Van Kesteren, M.: 
/. D. Res., 19:391, August 1940. 

25. McIntire, W. H., et al.: Indus. & Eng. 
Chem., 29:758, 1937. 

26. Volker, J. F.: Proc. Soc. Exper. Biol. 
& Med., 43:643, April 1940. 

27. Carnot, A.: Ann. de Mines, 1:155, 

1893- 

28. Smith, H. V., and Smith, M. C.: 
Waterworks Eng., 90 :1600, 1937. 

29. McIntire, W. H., and Hammond, J. 
W.: Indus. Eng. & Chem., 30 :160, 1938. 

30. Volker, J. F., et al.: J. Biol. Chem., 
134 : 543 , June 1940. 

31. Volker, J. F.: Proc. Soc. Exper. Biol. 
& Med., 42:725, December 1939. 

32. Norvold, R. W.; Inglis, J. H., and 
Armstrong, W. D.: ]. D. Res., 20:232, June 

1941. 

33. McClendon, J. F., and Foster, W. C.: 
Federation Proc., 2:34, 1943. 

34. Perry, M. W., and Armstrong, W. D.: 
J. Nutrition, 21:35, January 1941. 

35. Cox, G. J.: /. Am. Waterworks A., 31 : 
1926, 1939. 

36. Machle, W., and Largent, E. J.: J . 
Indus. Hyg. & Toxicol., 25 : 112 , March 1943. 

37. Bibby, B. G.: Tufts D. Outlook, 15 : 4 , 

1942. 

38. Idem: J. D. Res., 1943, to be pub¬ 
lished. 

39. Cheyne, V. D.: Human Dental Caries 
and Topically Applied Fluorine; Preliminary 
Report. J.A.D.A., 29:804-807, May 1942. 

40. Bibby, B. G.: J. D. Res., to be pub¬ 
lished. 




10 







THE USE OF FLUORINE IN THE PREVENTION 

OF DENTAL CARIES 

II. EFFECT OF SODIUM FLUORIDE APPLICATIONS 
B. G. Bibby,* B.D.S., Ph.D., D.M.D., Boston, Mass. 


I N two previous papers, lf 2 the avail¬ 
able information touching on the ac¬ 
tion of fluorine in preventing dental 
caries was analyzed, and the conclusion 
was reached that the caries-preventing 
effect of fluorine is principally the result 
of a direct reaction between the ex¬ 
ternal surfaces of the erupted teeth and 
fluorides in the drinking water or food. 
In these papers, it is suggested that the 
fluorine content of the teeth and their 
consequent resistance to caries could be 
increased by bringing them in contact 
with solutions of fluorides or other flu¬ 
orine-containing preparations. If actual 
clinical test proved that this was the 
case, not only would convincing proof of 
our conclusion on the mode of action of 
fluorine be provided, but also a new and 
important approach to caries prevention 
could be established. For these reasons, 
it became important to make a clinical 
study of the effect of applications of 
fluoride on the activity of dental caries. 

STUDY GROUP 

Through the assistance of Dr. Florence 
Hopkins, of the Dental Unit of the Mass- 
# Dean, Tufts College Dental School. 


achusetts Department of Health, and Mr. 
John Miller, then superintendent of the 
Brockton Schools, it became possible to 
carry out a study on the children at¬ 
tending Brockton Schools and to use the 
facilities of the school dental clinic. Be¬ 
cause more new caries appears immedi¬ 
ately after the eruption of the second 
molars, cuspid and bicuspids, and be¬ 
cause the appearance of these teeth pro¬ 
vides a new “caries-susceptible popula¬ 
tion” in the mouth, children from io to 
13 years of age were chosen as most 
likely to reveal any caries-preventing ef¬ 
fects from our treatments. A group of 
ioo children in this age group were se¬ 
lected by Miss Marie Blake, dental 
hygienist in the Brockton Schools, on the 
basis of willingness to cooperate, parental 
consent and, when there was one, the ap¬ 
proval of the family dentist. At the be¬ 
ginning of the experiment, the age 
distribution of children was as follows: 

10 to 10.5 years, 15 ; 10.5 to 11 years, 10; 

11 to 11.5 years, 21; 11.5 to 12 years, 
15; 12 to 12.5 years, 12; 12.5 to 13 
years, 3; 13 years, 4. The group was of 
mixed racial and national background, 
nineteen claiming American parentage, 


11 








fourteen Italian, eleven Irish, ten French, 
seven Syrian, three Swedish, three Lith¬ 
uanian and two Polish, with single rep¬ 
resentatives of other groups or national 
mixtures. 

Most of the children were receiving 
regular dental treatment at the school 
clinic, but some were ineligible, others 
would not submit to dental care and a 


health manifested themselves, but an 
unexpectedly high percentage showed 
microscopic hypoplasia of the teeth 
(Mellanby) or other signs of malnutri¬ 
tion. Largely as a result of changing 
conditions associated with defense em¬ 
ployment, a number of children were 
lost during the period of the study. Ninety 
of the original ioo children were exam- 


Table 1 .—Caries Increase Between First and Second Examinations 


No. of 

Fluoride Treated Quadrants 

- 

Untreated Control Quadrants 

Patients 











Reporting 

First Examination 

Reexamination 

First Examination 

Reexamination 

for Both 





















Examina- 


No. 

No. of 


Question- 


No. 

No. of 


Question- 

tions 

Quad- 

of 

Affected 

New 

able 

Quad- 

of 

Affected 

New 

able 


rant 

Teeth 

Surfaces 

Caries 

Change 

rant 

Teeth 

Surfaces 

Caries 

Change 

27 

UR 

144 

69 

7 

16 

UL 

145 

69 

21 

17 

17 

LR 

100 

32 

8 

11 

LL 

97 

29 

12 

21 

24 

UL 

139 

74 

8 

19 

UR 

139 

88 

13 

21 

22 

LL 

117 

37 

10 

16 

LR 

115 

38 

15 

17 

90 


500 

212 

33 

62 


496 

224 

61 

76 


Table 2 .—Caries Increase Between First and Third Examinations 


No. of 

Fluoride Treated Quadrants 

Untreated Control Quadrants 

Patients 











Reporting 

First Examination 

Third Examination 

First Examination 

Third Examination 

for Both 











Examina- 


No. 

No. of 


Question- 


No. 

No. of 


Question- 

tions 

Quad- 

of 

Affected 

New 

able 

Quad- 

of 

Affected 

New 

able 


rant 

Teeth 

Surfaces 

Caries 

Change 

rant 

Teeth 

Surfaces 

Caries 

Change 

24 

UR 

132 

56 

21 

34 

UL 

133 

54 

46 

31 

17 

LR 

100 

41 

14 

15 

LL 

97 

40 

15 

30 

21 

UL 

133 

51 

22 

26 

UR 

133 

64 

40 

29 

18 

LL 

99 

52 

26 

15 

LR 

97 

41 

23 

25 

80 


464 

200 

83 

90 


460 

199 

124 

115 


few had their own dentists. The state of 
the teeth was not considered in choosing 
the experimental group. The children 
evidenced considerable variation in 
caries-susceptibility, three showing com¬ 
plete absence of caries and two having 
cavities or fillings in virtually every exist¬ 
ing tooth. The remainder had between 
one and five affected permanent teeth. 
The usual variations in physique and 


ined at the end of the first year, and only 
eighty were available at the end of the 
two-year study. 

FLUORIDE TREATMENTS 

t 

Fluoride treatments were given in only 
one quadrant of each mouth. Different 
quadrants were selected and treated in 
different patients, so that an approxi¬ 
mately equal number of each quadrant 


12 

































































(upper left, lower left, upper right or 
lower right) were used for test purposes. 
The quadrant on the opposite side of the 
same jaw was used as a control. Because 
laboratory study had shown that 1/1,000 
sodium fluoride solution was almost as 
effective in reducing the solubility of 
enamel and dentin as were higher con¬ 
centrations, an aqueous solution of this 
strength was chosen for use in the mouth. 
A routine dental prophylaxis with pumice 
and peroxide was given by the dental 


with cotton swabs, alcohol and air. 
Thereafter, all surfaces of the controlled 
teeth were kept wet with the 1/1,000 
sodium fluoride solution for seven or 
eight minutes by means of repeated ap¬ 
plications of the solution on cotton wool. 
In some instances, the fluoride solution 
was worked into tooth fissures by means 
of an explorer. On completion of treat¬ 
ment, the excess fluoride was removed 
with the absorbent roll or cotton swabs 
and the mouth thoroughly rinsed with 


Table 3 .—Caries Increment During Two Years of Fluorine Therapy 



Number of 

Test Quadrants 

Control Quadrants 

Test 

Period 

Children 
Completing 
Period of Study 

New 

Caries 

Question¬ 

able 

Change 

Total 

Caries 

Increase 

New 

Caries 

Question¬ 

able 

Change 

Total 

Caries 

1 year 

90 

32 

69 

101 

59 

82 

141 

2 years 

80 

83 

90 

173 

124 

115 

239 


Table 4 .—Caries Increase in Various Teeth in Eighty Patients 


Tooth 

Group 

Procedure 

New 

Caries 

Questionable 

Change 

Total 

Caries 

Percentage 

Reduction 

Incisors and Cuspids 

Test 

12 

14 

26 

26 


Control 

23 

12 

35 


Bicuspids 

Test 

12 

18 

30 

25 


Control 

14 

26 

40 


Molars 

Test 

59 

58 

117 

29 


Control 

87 

77 

164 



hygienist to all the teeth in the mouth 
from two to twenty-four hours before the 
fluoride treatment was given. 

The procedure employed was as fol¬ 
lows : Both the test and control quadrants 
were swabbed with hydrogen peroxide to 
remove any adherent d6bris and, as far 
as possible, to clean out tooth crevices 
and interproximal spaces. The mouth 
was then washed out with water. The 
test side was isolated with cotton rolls 
and the surfaces of the teeth were dried 


water. Treatments of this sort were given 
at intervals of approximately four 
months during the period of the study, 
and thus each patient received six treat¬ 
ments prior to the final examination. 

CARIES EXAMINATION 

The amount of caries in each mouth 
was determined by means of a mirror 
and probe. Graphic recordings were 
made of each tooth, showing the extent 
of the caries present and the size and 


13 





































location of any fillings. Extracted, un¬ 
erupted or erupting teeth were recorded 
as such. As in all examinations of this 
kind, many areas were found that could 
not be definitely called either carious or 
caries-free. Such areas were listed sep¬ 
arately under “questionable change.” 
The second examination was made after 
a period of one year, immediately before 
the fourth fluoride treatment. The third 
examination was carried out after a two- 
year period, at the termination of the 
experiment. Changes in the condition of 
the teeth were observed for each patient 


surfaces that were carious in the corre¬ 
sponding control quadrants, and seventy- 
six caries-free surfaces in the control 
quadrants that were carious on the test 
side. In view of the normal symmetry 
of the attack of caries, this may be taken 
to indicate that there would be a slightly 
greater predisposition to caries in the 
test as compared with the control quad¬ 
rants. 

RESULTS OF FLUORIDE TREATMENTS 

The results of the examination of the 
ninety patients who completed the first 


Table 5 .- 


Total for 
Teeth 


New 

Ques¬ 

tion¬ 

able 

Molars 

Treated 

59 

58 

Control 

87 

77 

Bicuspids 

Treated 

12 

18 

Control 

14 

26 

Incisors and 
Cuspids 
Treated 

12 

14 

Control 

23 

12 


Table 5 .—Location of New Caries and Questionable Areas 


Percentage of Total Occurring in Different Locations 


Occlusal 

Mesial and 
Distal 

Buccal 

Lingual 

Bucco- 

gingival 

New 

Ques¬ 

tion¬ 

able 

New 

Ques¬ 

tion¬ 

able 

New 

Ques¬ 

tion¬ 

able 

New 

Ques¬ 

tion¬ 

able 

New 

Ques¬ 

tion¬ 

able 

61 

71 

17 

10 

10 

7 

0 

3 

3 

9 

59 

68 

16 

9 

8 

16 

5 

0 

7 

6 

50 

67 

50 

28 

0 

0 

0 

0 

0 

6 

50 

65 

43 

26 

0 

0 

8 

0 

0 

8 

0 

0 

100 

93 

0 

0 

0 

7 

0 

0 

0 

0 

92 

... 92 

0 

8 

4 

0 

4 

0 


Linguo- 

gingival 


New 


8 

6 


0 


0 


0 

0 


Ques¬ 

tion¬ 

able 


0 


0 


0 


0 


0 


showing any new caries or questionable 
changes on previously intact tooth sur¬ 
faces, increases in the size of existing cav¬ 
ities and new fillings placed in areas 
previously recorded as sound. In the 
original examination, the amount of 
caries in the test and control quadrants 
was about the same, the test quadrants 
having 212 affected surfaces that were 
carious and the corresponding controls 
on the other side, 224. In the test quad¬ 
rants, there were ninety-one caries-free 


year and the eighty who completed the 
second year of treatment are given in 
Tables 1 and 2. In these tables, question¬ 
able new caries, areas previously caries- 
free that had been filled and cavities 
that had shown a definite increase in 
size are grouped under “questionable 
change.” The increases in caries during 
the first year and during the two-year 
period are summarized in Table 3. The 
three tables show that the caries increase 
in the quadrants treated with sodium 


14 


















































































































fluoride is considerably less than that in 
the untreated or control quadrants. At 
the termination of the study, the former 
showed an increase of 173 definite and 
questionable cavities as compared with 
2 39 the latter. The striking aspect of 
the findings is that the greatest reduction 
was in the new caries. Over the two- 
year period, there were only eighty-three 
definite new cavities in the treated, as 
compared with 124 in the control, quad¬ 
rants. During the first year, the relative 
decrease in new caries was even more 
marked. Table 4 shows that the action 
of fluorides was effective on all types of 
teeth. Clinical observations seemed to 
indicate that the fluoride applications 
were particularly effective in controlling 
smooth surface caries, especially that oc¬ 
curring about the gingival margins in 
very susceptible patients. However, Table 
5, which compares the caries-reducing 
effect on different surfaces of the teeth, 
does not offer any support for this im¬ 
pression. 

DISCUSSION 

The findings just presented offer defi¬ 
nite proof that the activity of caries can 
be reduced by application of sodium 
fluoride to the surfaces of the teeth. Thus, 
support is given to our previously stated 
conclusion 1 ’ 2 that fluorine acts to prevent 
caries principally by combining directly 
with the enamel surface to increase its 
resistance to the action of acid. More 
important than this is the possible bear¬ 
ing of these findings on the prevention of 
dental decay. The fact that such a 
marked reduction in caries can be pro¬ 
duced by as few as three treatments 3 
with the fluoride solutions indicates the 
great potentialities of fluorine-containing 
reagents in the field of preventive dentis¬ 
try. It seems obvious that if infrequent 
treatment can cause such definite changes 
in the progress of caries, more frequent 
treatment, the use of improved technics 
of application or treatment using a more 
active fluorine reagent might accomplish 


a great deal more in the control of dental 
decay. Even if the results obtained in 
these experiments are not improved 
upon, an important practical step toward 
caries prevention has been made. 

Topical application of fluorides to the 
teeth represents only one of many ways 
in which fluorine therapy could be used 
to prevent dental decay. An earlier 
paper 2 mentions a number of other pos¬ 
sibilities, some of which are already on 
trial. Because improvements in methods 
of fluoride therapy will come only with 
time and continued experiment, there is 
a question as to how long dentists should 
wait before they put fluoride treatment 
into general use for caries prophylaxis. 
There is little doubt that if this proce¬ 
dure is not utilized fairly quickly by the 
dental profession, it will be presented to 
the public by other agencies. Provided 
suitable precautions are taken to prevent 
the swallowing of fluoride solutions, there 
seems to be no reason why dentists should 
not begin to use fluoride treatments of 
the sort described above on the teeth of 
caries-susceptible patients. Largent 4 has 
indicated that such sodium fluoride treat¬ 
ments “can be carried out without appre¬ 
ciable systemic absorption of the ma¬ 
terial.” 

SUMMARY 

Experiments on eighty children over a 
period of two years showed that six topi¬ 
cal application of a 1/1,000 sodium 
fluoride solution reduced dental caries 
by somewhat more than one-third as 
compared with results in the correspond¬ 
ing untreated quadrants in the same 
mouth. 

BIBLIOGRAPHY 

1 . Volker, J. F., and Bibby, B. G.: Medi¬ 
cine, 20:211, May 1941. 

2 . Bibby, B. G.: Use of Fluorine in Preven¬ 
tion of Dental Caries. J.A.D.A., 31:228, 
February 1, 1944. 

3 . Idem: Tufts D. Outlook, 15:4, May 
1942 . 

4 . Largent, E. J., and Moses, J. B.: Top¬ 
ical Application of Fluoride and Fluoride Ab¬ 
sorption. J.A.D.A., 30:1246, August 1, 1943. 


15 


)] ’ 


RAMPANT DENTAL CARIES: PREVENTION 

AND PROGNOSIS 

A FIVE YEAR CLINICAL SURVEY 


Hermann Becks, M.D., D.D.S.; Arthur L. Jensen, D.D.S., and 
Compton B. Millarr, D.D.S., San Francisco, Calif. 


INTRODUCTION 

HE prevention and prognosis of 
rampant dental caries have long 
been two of the most important 
and baffling problems confronting the 
dental and medical professions. In spite 
of recent developments in the field of 
preventive dentistry, the concept still pre¬ 
vails that the control* and prevention of 
dental caries rest entirely with operative 
procedures. This purely symptomatic 
treatment of filling cavities is used with- 

From the George Williams Hooper Founda¬ 
tion for Medical Research and the Division of 
Dental Medicine, College of Dentistry, Uni¬ 
versity of California. 

Conducted under grants made by the Ameri¬ 
can Foundation for Dental Science, California 
State Dental Association and Research Board 
of the University of California. 


out consideration of etiologic factors. 
Consequently, the disease continues to 
occur, often with increasing frequency. 
The present war emergency is bringing 
out with striking emphasis the fact that 
mechanical means alone are inadequate 
to meet this problem, especially since the 
dental manpower of the nation is insuf¬ 
ficient to take care of the reparative 
needs of both the armed forces and the 
civilian population. It is urgently neces- 

*In the past, the term “control of dental 
caries” has had the misfortune of a wide 
variety of interpretations. These ranged from 
the concept that “control” was achieved by 
repair of affected areas, to the attitude of 
mind which considered “control” as concerned 
with the correction of the fundamental etio¬ 
logic factors. Because of its possible misinter¬ 
pretation, the term “control” has been avoided 
in this report. 



16 









sary, therefore, to explore the possibili¬ 
ties of prevention. 

Several procedures have been sug¬ 
gested in the past. Some had as their 
main aim the removal of acidogenic 
micro-organisms from the mouth, which, 
since the time of W. D. Miller, have been 
suspected of being responsible for the 
production of this disease. Most of these 
procedures have been found to be im¬ 
practical and disappointingly unsuccess¬ 
ful owing largely to the necessity of wait¬ 
ing for a period of from six months to a 
year to test the effectiveness of any cor¬ 
rection. The many changes that occur 
during such a long period of time greatly 
obscure the accuracy of observations. 
However, the introduction of an immedi¬ 
ate quantitative laboratory test by Had¬ 
ley, Bunting and Delves in 1930 1 pro¬ 
vided a mechanism to determine caries 
activity at any given time by the presence 
of Lactobacillus acidophilus. Its applica¬ 
tion was first tested by Bunting, Jay et al. 
2,3,4,5, 6 , 7, 8 an( j confirmed by Becks, 9 
Enright, Friesell and Trescher 10 and 
Thompson. 11 

These preliminary studies offered great 
possibilities and it became increasingly 
apparent that this concept should under¬ 
go a thorough testing on a sufficient 
amount of material to determine its va¬ 
lidity and practical value. For this pur¬ 
pose, a program was developed in 1937 
which had as its objective answers to the 
following questions: 

1. Is L. acidophilus consistently present 
during dental caries activity and absent 
during caries inactivity? 

2. Is the reduction of refined carbo¬ 
hydrate intake effective in reducing the 
L. acidophilus index? 

3. Is the reduction of a high L. aci¬ 
dophilus index accompanied by a reduc¬ 
tion in dental caries frequency? 

MATERIAL AND PROCEDURE 

The project was divided into two 
parts: 

1. A study of the association of dental 


caries and L. acidophilus indices in two 
groups: (a) Individuals with rampant 
dental caries, (b) Individuals who are 
completely caries-free. 

The rampant caries group comprised 
1,250 individuals, 572 males and 678 fe¬ 
males, who had applied for preventive 
service during the last five years and 
ranged in age from 4 to 60 years. Ap¬ 
proximately half were 18 years or young¬ 
er. For purposes of standardization, only 
individuals who developed ten or more 
cavities within the preceding year were 
accepted as having rampant dental 
caries. 

The group completely caries-free was 
obtained from the student body of the 
University of California in Berkeley, com¬ 
prising 265 individuals between the ages 
of 18 and 54 years, including 170 males 
and ninety-five females. A preliminary 
report on some of these individuals has 
been made by Henningsen 12 and Collins, 
Jensen and Becks. 13 Their selection was 
based on clinical and roentgenographic 
oral examinations. The L. acidophilus in¬ 
dices were made for both groups on each 
of two successive days in order to de¬ 
termine whether a definite relationship 
exists. 

2. A study of the effect of reducing 
the intake of refined carbohydrates on 
the L. acidophilus index and subsequent 
caries experience in a large number of 
individuals with rampant dental caries. 

For this purpose, a five-year study was 
planned and the interval of one year was 
selected as the basic observation time. 
When the periods between the dental 
examinations varied from the one-year 
standard, the record was allocated to the 
nearest unit of one year. Through the 
cooperation of dentists and physicians 
who referred their most problematic cases, 
more than a thousand individuals with 
rampant caries were served in this five- 
year interval. From these, a total of 790 
one-year observations were made, 499 
being observed for one year, 111 for two, 
fifteen for three and six for four years. 


17 


Their ages ranged from 4 to 60 years in 
272 males and 359 females. Since each 
one-year observation represents the expe¬ 
rience of one individual during that pe¬ 
riod, for simplification reference will be 
made to individuals rather than to one- 
year observations. 

In order to recognize and evaluate the 
activity of dental caries accurately, it was 
necessary to follow meticulously a stand¬ 
ardized plan of examination so that all 
findings would be comparable. For this 
purpose, a staff of instructors and clini¬ 
cal assistants were assembled and trained. 
The standard method adopted included: 

1. Clinical and roentgenographic oral 
examinations. 

2. L. acidophilus index determination. 

3. Evaluation and change in food in¬ 
take. 

In order to familiarize the referring 
dentist or physician with the procedure, 
complete sets of instructions were sent on 
request.* 

Clinical and Roentgenographic Oral 
Examinations. —In order to enable the 
examiner to compute the caries experi¬ 
ence from successive examinations over 
an extended period of time, it was nec¬ 
essary to establish a systematic procedure 
of dental examination and an exact sys¬ 
tem of recording. For this purpose, all 
filled and unfilled carious areas were 
charted. The Bodecker Caries Index 14 
was used to express the total carious 
areas involved, and any change found on 
a subsequent examination was similarly 
recorded. This readily allowed the ob¬ 
servation of primary (new) or secondary 
caries (new involvement of areas previ¬ 
ously restored). For purposes of con¬ 
sistency and accuracy, each case was fol¬ 
lowed through by a team of examiners. 
From the standpoint of roentgenographic 
interpretation, the slightest observable 
nick or break in the regular contour of 
the enamel was noted and charted for 

*These are available by addressing the Divi¬ 
sion of Dental Medicine, University of Cali¬ 
fornia, Medical Center, San Francisco, Calif. 


each area. Even though it was desirable 
to have an entire denture roentgenogram 
available, posterior bite-wing films were 
accepted as the minimum requirement 
and were retaken once a year. The clin¬ 
ical oral examinations were repeated at 
least once a year and in many instances 
semiannually. 

L. Acidophilus Index Determinations. 
—The method employed for the determi¬ 
nation of the L. acidophilus index was 
that described by Hadley. 15 Initial saliva 
specimens were obtained on two succes¬ 
sive days, again one week after the 
change in food intake and monthly 
thereafter unless lack of response neces¬ 
sitated more frequent checks. These 
specimens were collected in the morning 
before breakfast and before brushing the 
teeth. The patient was instructed to chew 
vigorously a i-gm. piece of paraffin 100 
times on each side of the mouth and to 
expectorate all accumulating saliva into 
a sterile bottle. Mailing containers with 
detailed instructions, paraffin and sterile 
bottle were provided. Immediately upon 
receipt of the specimen, the saliva was 
plated, and incubated for four days. The 
colonies were then identified and counted. 
Routine reports were forwarded to both 
the referring dentist or physician and 
the patient. 

Evaluation and Change of Food In¬ 
take. —For purposes of listing the food 
taken, a record form was made avail¬ 
able to the patient with careful instruc¬ 
tions to record food intake for a typical 
one-week period. Times of unusual ac¬ 
tivity, such as vacations, trips and holi¬ 
days, were avoided. Indications of food 
preferences and dislikes were made, on 
both the basis of taste and the allergic 
reaction. Each patient was questioned as 
to the condition of physical health, re¬ 
cent illnesses or any systemic disturb¬ 
ances of which they were aware. This 
was done to facilitate collaboration with 
medical counsel as well as to avoid in¬ 
terference with any recommendations 
concerning food intake. 


18 



In evaluating these records, the 
amounts of refined carbohydrates were 
estimated and sugars and concentrated 
sweets were expressed in equivalents of 
teaspoonfuls of sugar. 13 The totals for the 
week were then averaged for daily con¬ 
sumption. The value of such records is, 
of course, open to question for at least 
the following reasons : i. Difficulty in 
securing a record that is a typical sam¬ 
ple of food intake. 2. Incomplete record¬ 
ing of kinds and amounts of foods eaten. 
3. Variation in sources and preparation 
of foods affecting the amounts of nu¬ 
trients. 4. Individual variations in effi¬ 
ciency of digestion, assimilation and 
utilization. 

In the future, quantitative analytic 
methods of determining the amounts of 
various nutrients in tissues and body 
fluids will possibly replace the present 
rather inadequate methods of assessing 
the food intake. However, until such 
methods have been satisfactorily es¬ 
tablished, it is necessary to resort to eval¬ 
uations which give at least an index to 
the trend. 

When the patient was first referred, 
arrangements were made to secure the 
salivary specimens, a record of the food 
intake for a period of seven days and en¬ 
tire denture or bite-wing roentgeno¬ 
grams. After an interval of approxi¬ 
mately ten days, in which time these data 
were received and the L. acidophilus in¬ 
dex determined, the patient was recalled 
for a detailed oral examination and 
consultation: 

The first recommendations for a 
change of food intake were based on the 
number of L. acidophilus present and the 
amounts of refined carbohydrates con¬ 
sumed. In general, * this required re¬ 
striction of the following foods: sugar in 
and on foods; all concentrated sweets 
such as jam, jelly, syrup, honey, raisins, 
dates, figs, prunes, currants and canned 
fruits, and candy, chewing gum, confec¬ 
tions, pastries and sweet beverages. The 
patient was also counseled to minimize 


prepared breakfast cereals and other 
highly refined cereal products. The ex¬ 
tent and severity of restrictions were 
found to be a highly individual matter, 
in that some patients had to be much 
more strict than others. In some in¬ 
stances, excesses of fresh fruits had to 
be curtailed for a time in order to bring 
about a reduction of the L. acidophilus 
index. To make up for the loss in cal¬ 
ories, the patient was advised to increase 
the intake of other foods; for instance, 
meat, eggs, vegetables, milk and milk 
products. In the majority of cases, such 
a recommendation resulted in an im¬ 
provement over the previous regime of 
food intake. In observing the individ¬ 
ual patient’s response, a check on any 
fluctuation in body weight was made. 
Height, weight and age standards, corre¬ 
lated with width measurements at chest 
and lilac crest, were used. 16 ’ 17 It was 
noted that there was frequently a loss of 
from 6 to 8 pounds in the first month or 
two of this regime, especially in individ¬ 
uals who were overweight at the start. In 
view of the wide range of variation in 
individual response, other measures 
used may be demonstrated in hypothet¬ 
ical cases. 

1. The L. acidophilus index dropped 
from high to zero or within a range of 
from 300 to zero: 

The patient was then advised to stay 
strictly on this regime for the next 
three months, on the assumption of a 
favorable prognosis. Additional speci¬ 
mens were taken each month, and if the 
index remained zero for three months, 
the patient was allowed one or two 
servings of a sweet dessert per week. The 
analysis of subsequent monthly speci¬ 
mens of saliva determined whether this 
was permissible. 

2. The L. acidophilus index was re¬ 
duced to a small fraction of its initial 
high level. 

The patient was encouraged to con¬ 
tinue strictly on this regime since, in 
some instances, the complete change re- 


19 


quired a longer period of time. If a 
zero index was obtained in the next 
monthly check, the patient was the 
structed to proceed as under (i). If the 
index did not drop within the 300 to 
o range, an additional consultation was 
arranged. 

3. The L. acidophilus index was re¬ 
duced only 50 per cent or remained 

high- 

This condition suggested three pos¬ 
sibilities: (a) The patient had failed 

to understand details of the nutritional 
recommendations and continued to in¬ 
clude foods that were favorable to the 


were checked at additional interviews. 

5. The L. acidophilus indices fluctu¬ 
ated from high to o intermittently. 

Here caries was found to be largely 
eliminated or reduced to a very low 
frequency and additional consultations 
were highly effective. 

6. The initial as well as subsequent 
L. acidophilus indices were o despite the 
fact that the dental examination revealed 
extensive decay. 

This indicated the possibility that the 
cavities present were the result of a pre¬ 
vious period of caries activity and that 
the disease was inactive at the time. 


Table 1 . —L. Acidophilus Index in Rampant Dental Caries and Caries-Free Groups 


Groups 

Number 

of 

Cases 

L. Acidophilus Index 

1 

2 

3 

4 

5 

0-299 

0 

300-999 

+ 

1,000-9,999 
+ +' 

10,000-49,999 
+ + + 

50,000+ 

+ + + + 

I. Rampant Dental 

1,250 

111 

43 

232 

392 

472 

Caries 


8 . 9 % 

3 . 4 % 

18.6% 

31.4% 

21 . 1 % 

Total 

1,250 

154=12.3% 

1,096 = 87.7% 

II. Caries-Free 

265 

208 

10 

34 

10 

3 



78.5% 

3 . 8 % 

12 . 8 % 

3.8% 

1 . 1 % 

Total 

265 

218 = 82.3% 

47 = 17.7% 


growth of L. acidophilus, (b) The pa¬ 
tient did not cooperate through lack of 
self-discipline or because of an environ¬ 
ment incompatible with such change, 
(c) Certain undisclosed constitutional 
factors interfered with the normal re¬ 
sponse. 

In such instances, additional consul¬ 
tations were necessary to determine the 
actual situation. 

4. The L. acidophilus index fluctu¬ 
ated from high to low intermittently. 

In such cases, it was observed that 
caries was apt to persist, but usually at 
a much lower rate than previously. Va¬ 
riations in cooperation or other causes 


For a correct interpretation, these cases 
required a check on the technic of sup¬ 
plying the specimen. In many instances, 
the patient had previously been coun¬ 
seled to reduce the intake of sweets. 
The initial indices, therefore, were ac¬ 
tually representative of the effective¬ 
ness of corrective procedure. 

7. The initial L. acidophilus index was 
o and subsequently rose to a high or 
fluctuating value. This occurred in a 
very small percentage of cases that pre¬ 
sented the same possibilities as exam¬ 
ples 3, 4 and 5. 

The question arises as to whether the 
elimination of excessive sweets and other 


20 










































refined carbohydrates is permissible from 
a general health and nutritional point of 
view. The current emphasis in popular 
advertising on the energy value of the 
many products predominantly containing 
refined carbohydrates must be regarded 
as distinctly biased. It is recognized that 
glucose is metabolized in the cell to pro¬ 
duce energy with carbon dioxide and 
water as the final waste products. How¬ 
ever, this is not a simple one-step process. 
There are a number of sequential steps 
and, for several of these, a specific cata¬ 
lyst must be present. If the catalyst is 
not available in adequate amounts, the 
reaction for which it is responsible 
slows down, the rate of energy produc¬ 
tion is reduced and the cell is faced with 
detoxification of waste products other 
than carbon dioxide and water. Each 
of these catalysts is in itself a complex 
organic compound and its presence de¬ 
pends on sufficient amounts of the many 
necessary nutrients. Thus “energy” de¬ 
pends not only on a generous supply of 
sources of glucose, but also upon an ade¬ 
quate supply of other nutrients. The 
body is in no way dependent on refined 
carbohydrates for the insurance of a 
smooth and efficient operation of such 
energy affording mechanisms. Actually, 
it can operate just as efficiently, if not 
better, on naturally occurring unrefined 
sources of glucose, which has the addi¬ 
tional virtue of supplying many other 
nutrients. It might be added that fats, 
proteins and all other carbohydrates, as 
well as sugars, are also sources of energy. 
Thus, the recommendations set forth for 
dental caries prevention are not only per¬ 
missible, but also highly desirable from 
the standpoint of energy, health and nu¬ 
trition, and are entirely in accord with 
the summary of the Council on Foods and 
Nutrition on some nutritional aspects of 
sugar, candy and sweetened carbonated 
beverages. 18 Great difficulties were often 
encountered when therapeutic recom¬ 
mendations were made for an in¬ 
creased intake of these refined carbohy¬ 


drates. This practice frequently resorted 
to by internists, pediatricians and ob¬ 
stetricians is regrettable because of the 
sequence of a state of rampant dental 
caries. 

RESULTS 

In discussing the results of this five- 
year survey, reference is made to the 
problems stated previously: 

i. Is L. acidophilus consistently present 
during dental caries activity and absent 
during caries inactivity? 

In Table i, it is seen that a total of 
1,250 patients with rampant dental 
caries (Group I) and 265 individuals 
completely caries-free (Group II) were 
studied for the presence or absence of 
L. acidophilus in order to explore the 
significance of the wide numerical range 
of L. acidophilus indices. An arbitrary 
classification of 0-299 (°)j3 00_ 999 (low), 
i j 00 °-9j999 (high), 10,000-49,999 (high) 
and 50,000 (high) and over was used. 
Since numerical bacteriologic counts are 
not mathematically exact, the ranges 
were also expressed as o, +, ++, 
~b + + and ++++ respectively (Ta¬ 
ble 1). 

The observations on the group of 
1,250 patients (Table 1, Group I) re¬ 
vealed the striking picture of a strong 
relation between high L. acidophilus in¬ 
dices and rampant dental caries. In 
fact, 1,096, or 87.7 per cent, had indices 
over 1,000, while only 154, or 12.3 per 
cent, were between 999 and o. 

In contrast to this, of the 265 caries- 
free individuals (Table 1, Group II), 
218, or 82.3 per cent, had indices be¬ 
low 1,000, while the remainder, or 17.7 
per cent, were over 1,000. (It is no¬ 
table that these findings are almost 
identical with those of smaller caries- 
active and caries-free groups previ¬ 
ously reported. 13 ) Many of this caries- 
free group with high indices, observed 
for a period of one, two or three years, 
developed caries in this later period, 
which indicates that these cases, though 


21 


Table 2 .—L. Acidophilus Index Response and Dental Caries Experience in 790 Rampant Caries 

Cases During One Year Following Nutritional Consultation 


c n 
















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22 


^Percentages calculated for the entire group of 790 individuals. 
^Percentages calculated for each of the ten groups. 




























































































































clinically caries-free at the time of in¬ 
itial observation, were actually caries- 
active. Their exclusion from the caries- 
free group would, therefore, improve the 
already significant figure of 82.3 per 
cent. Thus, the presence and absence 
of L. acidophilus is indicative of caries 
activity and inactivity, respectively. 

2. Is nutritional correction with spe¬ 
cial regard to reduction of refined car- 


typical response was obtained in this 
group which represents 69.8 per cent 
of the total, with indices dropping from 
high to o or low (Group I, a, b) and at 
times showing fluctuations (Group I, c, 
d). It may be noted that in approxi¬ 
mately one-third of all cases (Group I, 
a), L. acidophilus was eliminated com¬ 
pletely (0 index) for an entire year. In 
most instances, the response was abrupt 


Table 3. —L. Acidophilus Index Response in 438 Rampant Dental Caries Cases 
Following Nutritional Advice Through Referring Dentist or Physician 


Group 

L. Acidophilus Index Response: 

Total 

Group 

Per Cent 
of Total 

Number 

Per Cent 

I 

(a) High to 0 

151 

34.5 

70.0 

(b) High to low 

25 

5.7 

(c) High to 0, fluctuating 

83 

18.9 

(d) High to low, fluctuating 

48 

10.9 

II 

(a) 0 to 0 

21 

4.8 

6.9 

(b) 0 to low 

6 

1.4 

(c) 0 to low, fluctuating 

3 

.7 

III 

(a) 0 to high 

8 

1.8 

2.0 

(b) 0 to high, fluctuating 

1 

0.2 

IV 

High to high 

92 

21.0 

21.0 


Total 

438 




hohydrates effective in reducing the 
L. acidophilus index? 

The answer to question 2 is shown in 
Tables 2 and 3. In reviewing the rec¬ 
ords accumulated over the five-year pe¬ 
riod, considerable variations in L. aci¬ 
dophilus response were noted. The 790 
individuals were segregated into four 
groups (Table 2), which showed typical 
patterns of reaction to nutritional re¬ 
gimes recommended (Table 2). 

Group I: The most favorable and 


within a few days, following the re¬ 
striction of refined carbohydrate intake. 
In addition to this group with the clas¬ 
sical response, better than one-third 
more showed a marked reduction of the 
index, which reached the o or low levels, 
but was not maintained consistently 
throughout the year (Group I, b, c, d). 

Group II: The initial indices of this 
group (14.3) were o, which is atypical 
for rampant dental caries. Reference is 
made to the experience shown in Table 


23 
































































15 Group I. Some of these remained o 
(Group II a) and others rose to low and 
fluctuating levels (Group II, b, c). As 
mentioned previously, many of these in¬ 
itial o indices were due to the fact that 
the patient had received advice to re¬ 
duce the refined carbohydrate intake be¬ 
fore the first specimens of saliva were 
taken. Therefore, in the majority of 
these cases, their initial indices do not 
represent a state of caries activity, but 
rather the result of corrective measures. 
Their reaction for the remainder of the 
year compared favorably with that of 
Group I. Thus, by combining these two 
groups, it can be seen that in 84.1 per 


vidually, and repeated interviews showed 
that the majority of these 125 patients, 
15.8 per cent of the total, gave question¬ 
able cooperation. (Table 2.) 

During the five-year period, L. aci¬ 
dophilus indices were made for an addi¬ 
tional 438 individuals (Table 3), who re¬ 
ceived their nutritional advice from the 
Division of Dental Medicine through 
their dentist or physician without direct 
consultation with staff* members. The 
changes in the L. acidophilus index of this 
group were similarly favorable, although 
a somewhat higher percentage failed 
completely to respond (Group IV). The 
other group percentages tally closely with 


Table 4.—Summary of Dental Caries Experience Following Nutritional Consultation 


Total Number of 
Rampant Caries Cases 

Caries Experience During One-Year Observation Periods 

0 

1-2 

3-5 

6-9 

10 + 

790 

(Table 2, Groups I to IV) 

492 

62.3% 

140 

17.7% 

82 

10 . 0 % 

50 

6 . 3 % 

26 

3 . 3 % 

Total 

632 = 80% 

158 = 20% 

665 

(Table 2, Groups I and II) 

473 

71.7% 

115 

17.3% 

54 

8.1% 

20 

3 % 

3 

0.45% 

Total 

588 = 88.4% 

77 = 11 . 6 % 


cent of all cases, the I/, acxdop hxlu*s index 
was effectively reduced by the reduction 
of refined carbohydrate intake. 

Group III: This group comprised only 
4 per cent of the total and, similarly to 
Group II, started with atypical o indices. 
During the year of observation, the in¬ 
dividuals of Group III responded un¬ 
favorably and rose to high and fluctu¬ 
ating levels (Group III, a, b). 

Group IV: In contrast to Group I, a, 
which is classical for a complete re¬ 
sponse, this group (11.8 per cent) did 
not evidence any favorable reaction to 
corrective measures. 

The reasons for the lack of response in 
Groups III and IV were evaluated indi- 


those of Table 2. This shows that such 
a service can be effectively extended on a 
broad basis. 

A total of 1,228 individuals thus re¬ 
ceived recommendations for corrections 
(Tables 2 and 3) and 1,004, or 81.7 per 
cent, responded, with a significant reduc¬ 
tion in the L. acidophilus index. 

3. Is the reduction of a high L. aci¬ 
dophilus index associated with the reduc¬ 
tion of dental caries frequency? 

The results of the annual dental exam¬ 
inations were checked against the L. aci¬ 
dophilus index response of Groups I to IV 
of Table 2. Dental caries experience was 
expressed as o, 1 to 2, 3 to 5, 6 to 9 and 
10 and more cavities per year. As shown 


24 








































under question 2, Groups I and II re¬ 
sponded most favorably in the reduction 
of L. acidophilus indices after curtail¬ 
ment of the intake of refined carbohy¬ 
drates. A striking parallel is seen in the 
decrease ot dental caries activity for the 
same groups, as well as the continued ca¬ 
ries activity in Groups III and IV with 
persistently high L. acidophilus indices. A 
summary of the findings in Table 2 is giv¬ 
en in Table 4 for the entire 790 individ¬ 
uals (Group I to IV) and separately for 
the 665 (Groups I and II) which give 
the affirmative answer to the foregoing 
question. (Table 4.) 

If a preventive procedure aims at com¬ 
plete elimination of dental caries in one 
year’s time, it can be seen from Table 4 
that such a result can be achieved to the 
extent of 62.3 per cent of a group of 790 
patients suffering from rampant den¬ 
tal caries, or 71.1 per cent in a selected 
group of 665 individuals who had a more 
favorable L. acidophilus index response. 
If, however, the development of only one 
or two cavities is accepted as a good clin¬ 
ical result for individuals previously hav¬ 
ing rampant caries (ten or more cavities 
in the preceding year), these percentages 
of prevention rise to 80 per cent and 
88.4 per cent respectively. 

COMMENT AND CONCLUSIONS 

The many theories and concepts of the 
etiology of dental caries have never been 
substantiated by clinical investigations of 
sufficient scope and duration to establish 
their general acceptance. Probably the 
greatest advance in the prevention of this 
disease is due to the earlier writings of 
Bunting and Jay. Their efforts revived in¬ 
terest in Miller’s concept and supple¬ 
mented it by the introduction of a quan¬ 
titative bacteriologic test that made it 
possible to evaluate critically the merits, 
practicability and effectiveness of cor¬ 
rective procedures. 

The present investigation had as its 
main objectives to determine: the rela¬ 
tionship of L. acidophilus indices to den¬ 


tal caries activity and inactivity ; whether 
a high L. acidophilus index can be effec¬ 
tively influenced by reducing the exces¬ 
sive intake of refined carbohydrates and 
whether such a reduction would be ac¬ 
companied by a decrease in caries fre¬ 
quency. 

The findings may be summarized as 
follows: 

1. Caries activity and caries inactivity 
were found to be accompanied by posi¬ 
tive and negative indices respectively. In 
a group cf 1,250 rampant caries cases, 
1,096, or 87.7 per cent, had L. acidophilus 
indices over 1,000. The reverse picture 
was found in 265 caries-free individuals, 
218, or 82.3 per cent, of whom had 
L. acidophilus indices below 1,000. This 
contrast between the two groups demon¬ 
strates a definite relationship between the 
presence and absence of L. acidophilus in 
caries activity and inactivity respectively. 
Although there are other acidogenic mi¬ 
cro-organisms which may. play a sim¬ 
ilar role, L. acidophilus is consistently 
found whenever a state of rampant ca¬ 
ries exists and is absent during caries in¬ 
activity. Therefore, the presence of 
L. acidophilus constitutes a significant in¬ 
dex and establishes this index as a quali¬ 
fied laboratory indicator for diagnosis 
and prognosis of this disease. 

2. In 1,004 (81.7 per cent) of 1,228 
rampant dental caries cases, a reduction 
of the L. acidophilus index was obtained 
within a period of a few weeks by re¬ 
ducing the intake of refined carbohy¬ 
drates and replacing the calories derived 
from these foods by increasing the intake 
of meat, eggs, vegetables, milk and milk 
products. The comparatively small re¬ 
maining group either manifested insuffi¬ 
cient cooperation or were influenced by 
undisclosed factors. This high degree of 
success established the reduction of the 
intake of refined carbohydrates as at least 
one effective means of reducing the 
L. acidophilus index. 

3. The reduction of the L. acidophilus 
index resulted in a drastic decrease in 



25 


dental caries frequency. In a group of 
790 rampant caries cases (ten and more 
new cavities in the preceding year), the 
prevention of new cavities was achieved 
along with the reduction of the L. aci¬ 
dophilus index to the extent of 80 per 
cent. Of these, 62.3 per cent were ar¬ 
rested completely, while an additional 

17.7 per cent developed only one or two 
cavities during the following year. In the 
665 cases with a favorable L. acidophilus 
response, no new cavities developed in 

71.7 per cent and cavities were limited 
to one or two in 88.4 per cent. This in¬ 
cidence of favorable response establishes 
the definite relationship between the re¬ 
duction of the L. acidophilus index and 
the reduction of dental caries activity. 

From the experience gained in the last 
five years, it has become evident that a 
program of dental caries prevention 
based on L. acidophilus indices and cor¬ 
rective procedures could be entirely prac¬ 
tical and effective in private practice, 
institutional work and public health serv¬ 
ice. Even though the introduction of the 
laboratory procedure in individual pri¬ 
vate offices may not be economically feas¬ 
ible as yet, the establishment of clinical 
laboratory facilities in certain centers 
could make such a service readily avail¬ 
able to a large surrounding area. It is 
encouraging to note that some state 
health departments already offer this 
laboratory service. One of the distinct 
features of this test is that analysis of the 
sample can be delayed for several days 
after it is taken, permitting transporta¬ 
tion across the country if necessary. The 
entire procedure wherever applied need 
not interfere with other routine treat¬ 
ment because it can be accomplished 
within a few minutes. The effectiveness 
of correction can be determined within 
one week, and the time, effort and cost 
in these preventive procedures are only 
a fraction of those necessary for repair. 

Significant as the reported figures may 
appear, it must be realized that results 
will vary with the interest, experience 


and skill of the individual practitioner, 
clinical group or public health worker. 
The reduction in intake of refined carbo¬ 
hydrates may have good clinical results, 
but it does not explain the cause of the 
disease. 

For instance, occasional observations 
were made to the effect that some indi¬ 
viduals consumed large amounts of sugars 
without developing decay and others 
with a low sugar consumption devel¬ 
oped rampant dental caries. This sug¬ 
gests that in addition to excessive refined 
carbohydrate ingestion, other factors 
have a bearing on the course of this 
disease. In other words, it is not pos¬ 
sible to state that ingestion of refined 
carbohydrates or sugars or foods contain¬ 
ing sugars results in decay. It is, of 
course, conceivable that the formation of 
lactic acid is the result of local fermenta¬ 
tion of sugars and concentrated sweets. 
However, the extensive inclusion of these 
foods may impose a burden on various 
metabolic processes or accentuate a lack 
of other nutrients. The establishment of 
the L. acidophilus index as a qualified lab¬ 
oratory test may greatly facilitate 
further investigation of these unknown 
factors. 

For the successful application of these 
procedures, dental teachers and students 
of dentistry must acquire a sound under¬ 
standing of the fundamentals of nutrition 
and many other factors in physiologic 
well-being. The problem of dental caries 
prevention thus evolves from treatment 
at the hands of highly skilled technical 
dental experts alone to include consider¬ 
ations of all factors in a sound dento- 
medical approach. 

The writers wish to express their apprecia¬ 
tion to Dr. William G. Donald, university 
physician and director of Cowell Memorial 
Hospital, University of California, Berkeley, 
and the medical and dental staffs for their 
courtesy and cooperation in the course of 
these studies. 

Appreciation is gratefully expressed to Drs. 
Jack Bertoglio, Samuel Bleadon, Charlotte 
Greenhood, Pearle Hannah, Forest Horner, 


26 




Carl Norheim, James Pfister, W. B. Ryder, 
W. S. Smith, Walter Straub, W. W. Wain- 
wright and Don White for their active par¬ 
ticipation in this program. 

BIBLIOGRAPHY 

1. Hadley, Faith P.; Bunting, R. W., and 
Delves, Edna A.: Recognition of Bacillus 
Acidophilus Associated with Dental Caries. 
J.A.D.A., 17:2041, November 1930. 

2. Bunting, R. W., and Palmerlee, Faith: 
The Role of Bacillus Acidophilus and Dental 
Caries. J.A.D.A., 12:381, April 1925. 

3. Jay, Philip, anc} Voorhees, R. S.: Ba¬ 
cillus Acidophilus and Dental Caries. D. Cos¬ 
mos, 69:977, October 1927. 

4. Bunting, R. W., et al.: Prevention of 
Dental Caries Through Limitation of Growth 
of Bacillus Acidophilus in Mouth. J.A.D.A., 
16:224, February 1929. 

5. Jay, Philip; Crowley, Mary, and 
Bunting, R. W.: Preliminary Studies on Im¬ 
munology of Dental Caries. J.A.D.A., 19:265, 
February 1932. 

6. Jay, Philip, et al.: Bacteriologic and 
Immunologic Studies on Dental Caries. J.A. 
D.A., 20:2130, December 1933. 

7. Jay, Philip, et al.: Observations on Rela¬ 
tionship of Lactobacillus Acidophilus to Den¬ 
tal Caries in Children During Experimental 
Feeding of Candy. J.A.D.A., 23:846, May 
1936. 

8. Jay, Philip: Lactobacillus Acidophilus 
and Dental Caries. Am. J. Pub. Health, 28: 
759, June 1938. 

9. Becks, Hermann: Salivary and Bacteri¬ 


ological Considerations in Control of Dental 
Caries. /. Am. Coll. Dentists, 9:184, June 
1942. 

10. Enright, J. J.; Friesell, H. E„ and 
Trescher, M. O.: Studies of Cause and 
Nature of Dental Caries. /. D. Res., 12:759, 
October 1932. 

11. Thompson, Richard: Aciduric Organ¬ 
isms in Dental Caries. Proc. Soc. Exper. Biol. 
& Med., 29:103, October 1931. 

12. Henningsen, M. G. : Caries-Free In¬ 
dividuals: Report on Dento-Medical Investi¬ 
gations. J. California D. A., 17:i-io, January - 
February 1941. 

13. Collins, R. O.; Jensen, A. L., and 
Becks, Hermann: Study of Caries-Free Indi¬ 
viduals: II. Is Optimum Diet or Reduced 
Carbohydrate Intake Required to Arrest Den¬ 
tal Caries? J.A.D.A., 29:1169, July, 1942. 

14. Bodecker, C. F.: Modified Dental 
Caries Index. J.A.D.A., 26:1453, September 
1939- 

15. Hadley, Faith P.: Quantitative Method 
for Estimating Bacillus Acidophilus in Saliva. 
/. D. Res., 13:415, October 1933. 

16. Pryor, H. B., and Stolz, H. R.: De¬ 
termining Appropriate Weight for Body 
Build. J. Pediat., 3:6o8, October 1933. 

17. Lucas, W. P., and Pryor, H. B.: 
Range and Standard Deviation of Certain 
Physical Measurements in Healthy Children. 
J. Pediat., 6:533, April 1935- 

18. Counci} on Foods and Nutrition: Some 
Nutritional Aspects of Sugar, Candy and 
Sweetened Carbonated Beverages. J.A.M.A., 
120:763, November 7, 1942. 



27 




GINGIVITIS AND VITAMIN C 


J. S. Restarski,* M.D.S., D.D.S., and M. PijOAN,f B.A., M.D., Bethesda, Md 


INTRODUCTION 

URING the past few years, some 
reports in the literature 1 ’ 2 ’ 3 in¬ 
dicate a conflict of opinion re¬ 
garding the use of ascorbic acid in the 
treatment of gingivitis. From a clinical 
point of view, it must be said that the 
only known uses of vitamin C are the 
prevention of scurvy and the treatment 
of scurvy. 4 ’ 5 The possible exception to 
this, the action of the vitamin on the 


The material in this article should be con¬ 
strued only as the personal opinions of the 
writers and not as representing the opinion of 
the Navy Department officially. 

From the Naval Medical Research Insti¬ 
tute, National Naval Medical Center. 
^Lieutenant Commander (DC), USN. 
fLieutenant, MC-V(S), USNR. 


intermediary metabolism of aromatic 
amino, acids in premature infants, 6 is in¬ 
teresting, but requires further investiga¬ 
tion. The use of the vitamin in gingivitis 
is based on the assumption that this 
process is either due to a scorbutic 
process or that it is improved by the 
administration of extra ascorbic acid. It 
appears, therefore, that much of the con¬ 
fusion is based on evaluation of the local 
lesion in relation to a vitamin deficiency. 
It is therefore the purpose of this com¬ 
munication to present certain data and 
considerations which might clarify the 
problem. 

At first glance, the problem resolved 
itself into placing in categories the vari¬ 
ous bases for the existence of gingivitis, 
and secondly into accepting certain defi- 



28 








nitions for the various pathologic proc¬ 
esses. Within certain limitations, gingivi¬ 
tis can he classed broadly as follows : 

1. Gingivitis based on a great variety 
of mechanical, pathologic and constitu¬ 
tional conditions not related to vitamin 
C economy. 

2. Gingivitis based on an active 
scorbutic process wherein there is a 
marked tissue deficit of the vitamin and 
a resulting change in collagen formation. 

3. Gingivitis as a disease resulting 
from a one-time scorbutic process, but 
where the subject is at present 

(a) Consuming a maintenance intake 
of vitamin C. 

(b) Consuming less than the mainte¬ 
nance requirement of vitamin C. 

(c) Consuming more vitamin C than 
is necessary for maintenance economy, 
but having a deep seated gingival lesion 
which transcends the original defect. 

These, then, are the essential possibili¬ 
ties. It is obvious that any lesions des¬ 
cribed in Section 3 may very well belong 
in Section 1 or be concurrent with any 
of the processes mentioned in the other 
sections. The advent of pocket forma¬ 
tion and the presence of exudate super¬ 
imposes a new disease, and should the 
subject be scorbutic, this process must 
require specific dental therapy as well as 
the systemic care given to the patient. 

In order to clarify the following dis¬ 
cussion, it may be well to define the 
terms used. 

Gingivitis : Any inflammatory process 
involving the gums. 

Periodontal disease: Pyorrhea al- 
veolaris, Schmutz pyorrhea, diffuse 
atrophy, paradentitis, periodontoclasia, 
Riggs’ disease : Disease processes involv¬ 
ing the supporting structures of the teeth. 

Scurvy: A clinical entity dependent 
on a prolonged depletion of ascorbic 
acid in animal tissues, with a resultant 
morphologic change in the intercellular 
substance of certain mesenchymal deriv¬ 
atives. As a result, hemorrhages occur 
and the gums, lacking intercellular sub¬ 


stance, become boggy and swollen. Ac¬ 
cording to Hess, 7 absolute reliance must 
not be placed on gum changes for an 
early diagnosis, as usually they do not 
appear until late in the disease. The 
early signs of perifollicular hemorrhages 
and petechial spots are much more char¬ 
acteristic. In 1940, when Crandon 4 in¬ 
duced scurvy in himself, there were no 
gum changes whatsoever, but all other 
signs and symptoms of scurvy were pres¬ 
ent and tissue biopsies revealed little or 
no collagen. However, it is well to bear 
in mind that stress modifies and at times 
determines the site of gross lesions. Thus, 
the gums are often subjected to trauma 
by chewing, etc., and separation may 
occur on a mechanical basis, promoting 
periodontal disease. 

Maintenance Intake of Ascorbic Acid. 
—The amount of ascorbic acid, either 
synthetic or derived from food, needed 
to prevent scurvy and which maintains 
a sufficient and a somewhat constant 
content of the white-cell tissue layer ol 
the blood or other tissues is the daily 

j 

minimal requirement. This may be re¬ 
lated to time and function, so that spo¬ 
radic increased intakes of the vitamin may 
compensate for periods of inadequate 
intake. 5 ’ 8 Such an intake averages about 
25 mg. of ascorbic acid a day for a 
twenty-one month period in the normal 
adult subject. 5 

At other times, subjects consuming 
large doses of ascorbic acid become sat¬ 
urated, and protection against scurvy 
for a period of from four to six months 
exists even though the subject consumes 
none or little of the vitamin. 4 This is 
evident in natives consuming fruits high 
in ascorbic acid in season, and relatively 
little at other times. 9 

Therapeutic or Curative Intake of 
Ascorbic Acid .—An undramatic and slow 
response occurs when the small main¬ 
tenance dose of ascorbic acid or slightly 
more is administered to the scorbutic 
subject. Relatively small doses may take 
weeks to have the necessary therapeutic 


29 



ft 


effect. Thus, large doses of the vitamin, 
of 150 mg.-1,000 mg., should be given 
daily. After treatment, the patient can 
be placed on a maintenance dose. Some 
investigators 17 have confused the main¬ 
tenance minimal intakes with optimum 
therapeutic doses of the vitamin. 

Criteria for the Evaluation of Scurvy. 
—The diagnosis of this disease must be 
based on the clinical picture, which has 
been amply discussed elsewhere. 4 ’ 5 The 
use of the saturation tests and urinary 
excretion tests, as well as plasma as- 


whether ascorbic acid economy is dis¬ 
turbed in gingivitis, thus requiring an 
increased intake of the vitamin for thera¬ 
peutic purposes. In regard to the first 
problem, it seems unlikely that the cases 
of gingivitis ordinarily seen are in any 
way related to scurvy. Ungley 13 and 
King 14 clearly showed that administra¬ 
tion of vitamins in large doses failed to 
exert any beneficial effect on gingivitis. 
Ralli 15 pointed out some time ago that 
gingivitis may, in general, have a multi¬ 
plicity of causes other than scurvy, and 


Certain Findings Related to Scurvy and Gingivitis* in Six Adult Subjects 

on a Scorbutic Regime! 


Ascorbic Acid 




Sex 

Initial Values 

2 Months 

4 Months 

5-6 Months 

OUU|Ctl 














Plasma 


Plasma 


IjPlasma 


Plasma 




Plasma{ 

& White 

Plasma 

& White 

Plasmalf 

& White 

Plasmalf 

& White 





Cells# 


Cells 


Cells 


Cells 

J. K. 

26 

$ 

1.1 

30.0 

0.2 

20.0 


11.0 


Trace 

M. W. 

42 

$ 

0.96 

32.0 

None 

18.0 


6.0 


None 

T. L. 

38 

4 

1.0 

32.0 

None 

18.0 


8.0 


Trace 

C. L. 

64 

$ 

1.2 

28.0 

0.1 

22.0 


10.0 


None 

A. M. 

36 

9 

0.96 

30.0 

None 

20.0 


10.0 


4 

C. A. 

26 

9 

| 0.96 

26.0 

None 

16.0 


7.0 


None 


^Initially, the gums were negative (no scurvy). The tests at two months continued negative. At four 
months, there was still no scurvy, and the gum condition was negative, except for soreness in subject 
C. L. and questionable findings in M. W. At five-six months, the gums were negative except for swelling, 
tenderness and bleeding in subject M. W. The scorbutic findings were positive at this period except in 
subject A. M. 

fThe teeth were carefully brushed, the subject using a fine castile soap morning and night. 

{Milligrams per hundred cubic centimeters. 

#Milligrams per hundred grams. 

UNone. 


corbie acid values, do not contribute to 
the diagnosis of scurvy. 5 * 11 ’ 12 If, on the 
other hand, the blood tissues, i.e. the 
white-cell platelet layer, values are low, 
or zero, the diagnosis of scurvy will 
receive adequate laboratory confirma¬ 
tion. 4 ’ 5 ’ 11 

THE PROBLEM : THE RESULTS 

The problem resolves itself into two 
phases: (1) to ascertain whether gingi¬ 
val disease parallels a depletion of as¬ 
corbic acid, and (2) to determine 


Crandon 4 failed to develop gingival 
lesions during his experience as a scorbu¬ 
tic. On the other hand, numerous in¬ 
vestigators 18 ’ 19 have combined vitamin 
C therapy with dental hygiene and 
dental procedures and have reasoned 
that such a form of treatment gave sat¬ 
isfactory results. Since gingivitis is a 
disease with various manifestations and 
etiology, the conclusions drawn were un¬ 
warranted. In some reports, the assump¬ 
tion that subclinical scurvy existed was 
based on the saturation test with vitamin 


30 





























C. This test is dependent on urinary 
elimination of a large amount of a test 
dose of ascorbic acid. It has been sup¬ 
posed by some that if no ascorbic acid 
is eliminated after such a dose, the 
subject is deficient in this vitamin. This 
has been shown 0 not necessarily to indi¬ 
cate scurvy. Others 16 assumed that low 
plasma vitamin C values were indicative 
of scurvy. The plasma vitamin G is 
always zero in scurvy, but it can also 
be so in non-scorbutic states, since it is 
the presence of the vitamin in the blood 
tissues (white-cell platelet layer) that is 
significant. 4 ’ 5> 10 ’ 11 

Six subjects, volunteers, after satura¬ 
tion with vitamin C, were placed on an 
ascorbic acid free regime (Table i). 

The diet consisted of eggs, cheese, 
cooked cereals, a variety of beans, bran 
flakes and debittered yeast and contained 
all vitamins with the exception of ascor¬ 
bic acid. A variety of dishes were pre¬ 
pared from the above and numerous sea¬ 
soning adjuvants were used. On the 
whole, the diet was well tolerated. 

The diagnosis of scurvy during the 
fifth and sixth months was based on the 
appearance of perifollicular hemorrhage 
and petechiae. Some had moderate and 
diffuse cutaneous hemorrhages over the 
thigh. None of the subjects objected to 
these findings. Lassitude and fatigue 
took place during the fourth month. 
After the advent of scurvy, treatment 
was immediately instituted with i gm. 
of ascorbic acid a day and a regular diet. 

It would be difficult to say what gum 
changes might have occurred if the pa¬ 
tients had been maintained on this re¬ 
gime. It is highly probable that gingivitis 
would have manifested itself. On the 
other hand, the data indicate that a 
shortage in the vitamin (in this case, a 
lack of it) does not readily lead to gingi¬ 
vitis. With the exception of one subject 
none had any noticeable changes in the 
gum tissues. It is well to point out that 
the diet was essentially a bland one, and 
that if more active chewing had taken 


place, the gums might have been more 
easily injured. The fact that pressing 
and scraping the papillae in an occasional 
test did not bring about a marginal gin¬ 
givitis supports the view that gingivitis 
is a late manifestation of scurvy and that 
it is not easily induced by a scorbutic 
regime. At least, the evidence suggests 
this concept. 

Concomitantly with this study, a series 
of patients were chosen in whom the 
actual pyorrhea was minimal, but gingi¬ 
vitis fairly pronounced. Out of a group 
of about sixty subjects with pyorrhea and 
gingivitis, only eighteen could be placed 
in this category. The others had deep 
seated pocket formation and exudate. 
The plasma ascorbic acid levels in these 
eighteen subjects varied from 0.2 to 0.6 
mg. per hundred cubic centimeters. The 
white-cell platelet values varied from 
16 to 24 mg. per hundred grams. These 
determinations were carried out at in¬ 
tervals of four days for three separate 
tests. On the whole, the values remained 
approximately within the range of the in¬ 
itial ones, and since the values were no¬ 
where in the limits of scorbutic values, a 
positive state of ascorbic acid economy 
existed. The use of 1 gm. of ascorbic 
acid and 3 glasses of fresh orange juice 
daily for three weeks failed to alter the 
condition in any way. No dental hy¬ 
giene was used. A group of twenty 
cases with a much more advanced py¬ 
orrhea process and with a somewhat sim¬ 
ilar ascorbic acid economy of the blood 
tissues, but who received no ascorbic acid 
whatsoever (placed in the diet of the 
six subjects studied), showed the usual 
variable improvement with local ther¬ 
apy. In about one-third, there was 
definite improvement; in one-third, no 
change, and in one-third, the results 
were equivocal. All of these subjects 
were hospitalized. It was, furthermore, 
the impression of the dental consultants 
that a bland diet contributed to the 
treatment of pyorrhea and gingivitis, 
the gums being subjected to less trauma. • 


31 


There is no way to exclude the possi¬ 
bility that gingivitis in some cases may 
have been due to some early scorbutic 
process and, with chronic infection and 
pyorrhea, the dental condition persists 
regardless of subsequent ascorbic acid 
intake. It is our impression that such an 
etiology is unlikely. 

CONCLUSION 

The assumption that gingivitis, with 
or without pyorrhea, is on a scorbutic 
basis is unwarranted unless there is ante¬ 
cedent or present clinical evidence of 
scurvy. The only* laboratory confirmation 
of the diagnosis being a depleted white- 
cell platelet ascorbic acid content, no 
other test with the exception of the index 
gained by whole blood values is reliable. 

Gingivitis and its periodontal mani¬ 
festations is, in most instances, a local 
lesion, and its connection with systemic 
processes requires considerable additional 
study. 

Acknowledgment is due to Dr. M. 
Frank, with whose help and cooperation 
this study was made possible. 

BIBLIOGRAPHY 

1. Roff, F. S., and Glazebrook, A. J.: 
Therapeutic Application of Vitamin C in 
Peridental Disease. /. Roy. Nav. M. Serv., 
25:340, October 1939. 

2. Stuiil, F.: Vitamin C Subnutrition in 
Gingivostomatitis. Lancet, 1:642, May 22, 

* 943 - 

3. Hanke, M. T.: Relation of Diet to 
General Health and Particularly to Inflamma¬ 
tion of Oral Tissues and Dental Caries. 
J.A.D.A., 27:957, June 1930. 

4. Crandon, J. H.; Lund, C. C., and Dill, 
D. B.: Experimental Human Scurvy. New Eng¬ 
land J. Med., 223:353-369, September 5, 
1940. 

5. Pijoan, M., and Lozner, E. L.: Physio¬ 
logical Significance of Vitamin G in Man. 
New England J. Med., 231 :14, 1944. 


6. Levine, S. Z. ; Gordon, H. H., and 
Marples, E.: Defect in Metabolism of Tyro¬ 
sine and Phenylalanine in Premature Infants. 
J. Clin. Investigation, 20:209, March 1941. 

7. Hess, A. F.: Scurvy, Past and Present. 
Philadelphia: J. B. Lippincott Co., 1920. 

8. Pijoan, M., and Roskelley, R. W.: Nu¬ 
trition and Certain Related Factors of Span¬ 
ish Americans in Western Colorado. Rocky 
Mountain Council on Inter-American Af¬ 
fairs, Denver, 1943. 

9. Goubaud, A.: Personal communication 
to the authors. 

10. Butler, A. M.: Vitamin C Deficiency. 
M. Clin. North America, 27:441, March 1943. 

11. Butler, A. M., and Cushman, M.: Dis¬ 
tribution of Ascorbic Acid in Blood and Its 
Significance. /. Clin. Investigation, 19:459- 
467, May 1940. 

12. Riestschel, H., and Mensching, J.: 
Experimenteller C-Vitamin-hunger am Men- 
schan, ein Beitrag zur Frage des C-Vitamin 
bedarfs. Klin. Wchnschr., 18:273, February 
25 , 1939 - 

13. Ungley, C. C., and Horton, J. S. F.: 
Bleeding Gums in Naval Personnel, Vitamin 
C and Nicotinic Acid Intake. Lancet, L397- 
399, March 29, 1943. 

14. King, J. D.: Nutritional and Other 
Factors in “Trench Mouth” with Special 
Reference to Nicotinic Acid Component of 
Vitamin B- Complex. Brit. D. ]., 74:113-122, 
March 5; 141-147, March 19; 169-176, April 
2, 1943 - 

15. Ralli, E., and Sherry, S.: Adult 
Scurvy and Metabolism of Vitamin C. Medi¬ 
cine, 20:251, September 1941. 

16. Abt, A. F., and Farmer, C. J.: Vitamin 
C: Pharmatology and Therapeutics, in the 
Vitamins, a Symposium. Chicago: American 
Medical Association, 1939, pp. 411-442. 

17. Kyhos, E. D., et al.: Minimum Ascorbic 
Acid Need of Adults. /. Nutrition, 27:271, 
1944. 

18. BurrilL, D. Y.: Relationship of Blood 
Plasma Vitamin G Level to Gingival and 
Periodontal Disease. J. D. Res., 21 : 353 , 
August 1942. 

19. Buchanan, J. W.: Hypovitaminosis C 
and Infective Gingivitis. /. Roy. Nav. M. 
Serv., 29:249, October 1943. 



II. PROTECTIVE DENTISTRY 



THE LOCAL USE OF SULFANILAMIDE AND SUL- 
FATHIAZOLE IN EXTRACTION WOUNDS; 

A PRELIMINARY REPORT 

By FIRST LIEUTENANT LEONARD WEINER, A.B., D.M.D., Dental Reserve 


I. Introduction 
HE local application of sulfanila¬ 
mide in tooth sockets is being 
practiced empirically by many 
men in dentistry today. This paper is 
a preliminary report on the use of sul¬ 
fanilamide and sulfathiazole prophy- 
lactically and therapeutically. The re¬ 
ports on the local use of sulfanilamide 
are very promising. Jensen, Johnsrud, 
and Nelson 1 applying it locally in 39 
compound fractures found all healing 
by primary intention; whereas in an¬ 
other series of 94 cases of compound 
fractures 20% became infected, though 


the treatment remained precisely the 
same except for the use of the pow¬ 
dered sulfanilamide. The authors 
found that administering the drug or¬ 
ally produced a blood level of 10-15 
mg% while the local implantation gave 
a concentration of 800 mg% in the 
area; a concentration which lasted for 
36 hours. According to Key and Fran- 
kel 2 at this concentration the drug is 
no longer bacteriostatic but is rather 
bactericidal. Of the local use of sulfa¬ 
thiazole Spink and Hansen 3 say “re¬ 
sults have been highly satisfactory and 
merit further investigation.” It is on 



34 




' 1 

f 


the basis of such reports that this at¬ 
tempt to evaluate, the effectiveness of 
these chemotherapeutic agents in den¬ 
tistry is made. 

II. The Literature 

The sulfonamides and their deriva¬ 
tives have been reported to be effective 
in varying degree for a large number 
of organisms, including pneumococ¬ 
cus, 4,5,6,s streptococcus beta hemolyti- 
cus 4,5,6,8 meningococcus, Lancefield’s 
Group beta hemolyticus streptococcus 
A, D, and G, 4 ’ 8 staphylococcus au¬ 
reus, 4 ’ 7 ’ 8 ’ 9 Bacillus proteus 3,4,7 gono¬ 
coccus, 7 ’ 8 streptococcus faecales, 7 aero- 
bacter aerogenes, 7 streptococcus alpha 
hemolyticus, 3 ’ 7 and staphylococcus al- 
bus. 7 Since the bacteria cultured from 
post-operative dental infections are to 
be found among these organisms, it 
seemed only reasonable to assume that 
these drugs would be effective in dental 
septic conditions. Spink and Hansen 3 
using powdered sulfathiazole topically 
in 36 patients with staphylococcus sep¬ 
sis found the results to be “highly sat¬ 
isfactory,” while Edwards 10 concluded 
that “sulfanilamide is definitely of 
value in the treatment of streptococcic 
infections of the mouth and jaws.” 
Lockwood 11 however says that sulfona¬ 
mide “is probably of limited value in 
bone foci.” Spink and Paine 12 in a small 
series of cases report that wound infec¬ 
tions seem to heal more rapidly when 
sulfathiazole is applied locally. It is of 
especial value in the treatment of 
chronic osteomyelitis. Hubbell and 
Austin 13 however found no difference 
between the healing of control sockets 


and that of sockets containing thera¬ 
peutic dressings (one of the dressings 
was sulfanilamide in lanolin). Law¬ 
rence 8 reports the bacteriostatic action 
of sulfathiazole in vitro to be greater 
than that of sulfanilamide for beta 
streptococcus Group A. Long and 
Bliss 4 think that sulfathiazole is fully 
as bacteriostatic as sulfanilamide in 
vitro for the particular group of 
organisms with which they worked. 
Archer 14 found that sulfanilamide re¬ 
duced the time of treatment of a “dry 
socket” by 50 per cent. 

III. Methods 

No attempt was made to select the 
patients except that as many subjects 
as possible were those who had multi¬ 
ple extractions in which three or more 
teeth were extracted at a single opera¬ 
tion. In these patients one socket was 
filled with sulfathiazole, a second with 
sulfanilamide, the third was kept as a 
control. Thus in these cases of multiple 
extractions which constitute 30.14% of 
the 1,065 extractions performed, all 
systemic factors remained constant for 
the individual patient except the agent 
used. The drugs were obtained in tablet 
form, but were broken into small pieces 
before they were packed into the socket. 
No curettage was done previous to the 
insertion of the drug nor was any at¬ 
tempt made to use sterile drugs. Key 
and Frankel 2 recommend that the 
drugs be sterile before using them lo¬ 
cally. The patients, save in some few 
isolated instances, were followed daily 
for about a week. All teeth were ex¬ 
tracted under conditions of as complete 


35 


I 

asepsis as possible. Following the ex¬ 
tractions sedatives were prescribed. 
Almost all of the hospital patients en¬ 
tered the institution for reasons other 
than dental, 25.7% being classified as 
poor risks due to their systemic condi¬ 
tions. 

Therapeutically in the two cases 
which entered the hospital with an al¬ 
ready diagnosed condition of localized 
osteomyelitis or “dry socket” and in 
those sockets which became infected 


those in which sulfathiazole was used. 
None of these showed any of the clini¬ 
cal signs of the “dry socket.” 

Two facts are notable: 

First, that each of two patients had 
two sockets which became infected; 
agreeing with Hubbell and Austin 13 in 
whose experimental animals such “dry 
sockets” as did occur were in a single 
animal. 

Second, that all the post-operatively 
infected sockets occurred in the mandi- 


Table I 
Extractions* 


Sockets 

Teeth 

upper lower 

Total 

Number infected 
upper lower 

Per cent 

Control 

201 

142 

343 

0 

5 

1.46 

Sulfathiazole 

169 

212 

381 

0 

1 

0.26 

Sulfanilamide 

177 

164 

34 i 

0 

0 

0.00 


*631 of the extractions were performed on hospital patients. 


post-operatively, the following proced¬ 
ure was adopted: 

1. Take culture from socket 

2. Debridement of socket 

3. Irrigate socket thoroughly with 
warm saline solution 

4. Pack socket carefully with sulfa¬ 
thiazole 

T here were only three patients who 
showed the clinical symptoms of the 
so-called “dry socket” or alveolalgia, 14 
or localized osteomyelitis; of these, two 
had had the diagnosis made by their 
dentist before entering the hospital. 
The third occurred in one of the con¬ 
trol sockets of a hospital patient who 
was considered to be in good health. In 
addition to these, four of the control 
sockets became infected as did one of 


ble, where drainage is not as good as in 
the maxilla. 

IV. Results 

A. Prophylactic Use of Drugs 

A total of 1,065 extractions were per¬ 
formed ; of these 343 not given chemo¬ 
therapy were controls, 381 were packed 
with sulfathiazole, and 341 were 
treated with sulfanilamide. Five infec¬ 
tions developed in the controls, one of 
these progressing to the point where it 
showed clinical manifestations of the 
“dry socket.” Of the 381 prophylacti- 
cally treated with sulfathiazole but one 
case of infection occurred, and this in a 
man who also had a control socket 
which became infected. No infections 
followed the prophylactic use of the 
sulfanilamide. 


36 



















B. Therapeutic Use of the Drugs 

In treating the infection therapeu¬ 
tically the drug chosen was sulfathia- 
zole for the reasons that it is less toxic 
than sulfanilamide and for many types 
of organisms more effective. Also the 
small number of cases rendered it ad¬ 
visable to better test the efficacy of a 
single drug rather than two and obtain 
no indication of either’s true ability to 
abort the infection. 

Case i 

J. R., a 25 year old male, had his 
lower left premolars extracted by his 
dentist on November 2. Pain was not 
severe on the 3rd, but grew worse on 
the 4th. He returned to his dentist on 
the 5th, who gave him a sedative tab¬ 
let. The pain did not abate, rather be¬ 
coming more severe, so that he revis¬ 
ited his dentist on the 7th, on which 
date a partly exfoliated sequestrum was 
removed. He entered the hospital on 
the evening of the 7th to have a hemor¬ 
rhoidectomy performed. He was seen 
by the writer about two hours after ad¬ 
mission who informed the patient’s sur¬ 
geon of the oral condition and on whose 
advice the anesthetic agent was changed 
from one of inhalation to sodium penta- 
thol. His condition consisted of a 
slightly swollen left mandible with 
severe pain. Pressure along the margins 
of the sockets was extremely painful 
and caused pus to well out. A culture 
was taken, then the sockets filled with 
sulfathiazole, but no debridement was 
performed. For sedation he was given 
1/6 grains of morphine sulfate. The 
hemorrhoidectomy was performed on 


the 8th and the patient was seen by the 
writer on the evening of the same day. 
His dental condition was slightly bet¬ 
ter, the ache being dull rather than 
sharp, though pus was still present. On 
the 9th the sulfathiazole was again put 
into the sockets, pain and pus still pres¬ 
ent. Sedatives were given daily. The 
report of the culture taken on the 7th 
showed:* 

1. Streptococcus—beta hemolyticus 
type, 2 + 

2. Streptococcus—alpha hemolyticus 
type, 2 + 

On the nth there was no apparent pus, 
but the dull ache was still present. On 
the 12th, the sockets were very slightly 
curetted, irrigated, and sulfanilamide 
packed into them. On the 13th there 
was no pain, no sign of infection, and a 
culture then taken proved negative. In 
the treatment of this case the failure to 
irrigate the sockets when the patient 
was first seen may have prolonged the 
infection. Lockwood 11 has shown that 
the presence of peptones in the necrotic 
tissue inhibits markedly the ability of 
the sulfonamide derivatives to be bac¬ 
teriostatic. 

Case 2 

E. D., 20 year old female, had her 
lower right second premolar extracted 
on October 19 by her dentist. The pain 
was quite noticeable on the 20th, but 
circumstances prevented her seeing her 
dentist again until the 23rd, at which 
time he applied local medication. She 
revisited him on the 24th when he 

* Cultures were examined only for strepto¬ 
cocci and staphylococci. 


37 


curetted and placed a drain into the 
socket. On the 25th he changed drains 
and irrigated the socket. She entered 
the dental clinic on the 26th with sharp 
“shooting” pains. Removal of the drain 
revealed pus in the socket. A culture 
was taken, the socket curetted slightly 
and then filled with sulfathiazole. Seen 
again on the 27th she said there was 
little pain, while a swab put into the 
socket brought forth only a slight puru¬ 
lent odor but no pus. The socket was 
again irrigated and packed with sulfa¬ 
thiazole. Revisiting the clinic on the 
29th, the patient reported that the pain 
had ceased to trouble her on the eve¬ 
ning of the 27th. The original culture 
revealed: 

1. Staphylococcus albus, 2 + 

2. Streptococcus—beta hemolyticus 
type, 1 + 

3. Streptococcus—alpha hemolyticus 
type, 2 + 

A final culture taken on the 29th was 
negative for these organisms. 

Case 3 

P. D. C., 21 year old male had his 
lower left first molar extracted on the 
29th of the month. He had some pain 
on the 30th, but no swelling. Curet¬ 
tage of the socket showed pus to be 
present. In this instance no therapeutic 
treatment was carried out. Aspirin was 
prescribed for sedation. On the 31st 
the patient reported that the pain at 
night was such as to prevent restful 
sleep. No swelling or pus was evident. 
Codeine in grain doses every four 
hours was given in addition to the as¬ 
pirin. On the third day, the patient 


was still in pain and unable to sleep. 
No pus was seen nor was there any 
soft tissue swelling. For sleep ip2 
grains of phenobarbital was prescribed 
at bedtime. The status quo did not 
change for the 4th, 5th, or 6th days. 
On the 7th day treatment was insti¬ 
tuted because the patient was suffering 
from intense pain. A culture was taken, 
then the socket was carefully freed of 
debris and pus was obtained. The socket 
was then irrigated with warm saline 
which was followed by filling it com¬ 
pletely with sulfathiazole. The patient 
complained of pain on the following 
day despite the continued sedation. No 
free pus was apparent. The socket was 
again very slightly curetted, irrigated, 
and packed with sulfathiazole. He was 
also given the drug orally, 105 grains 
per day. On the 9th day he reported 
less pain and that he had slept most of 
the night. Upon examination no pus 
was evident. Treatment of the previ¬ 
ous day was repeated. On the 10th day 
he reported no pain and the socket did 
not appear infected. A culture was 
taken. 

The culture taken on the 7th day re¬ 
vealed : 

1. Streptococcus—beta hemolyticus 
type, 3 + 

2. Streptococcus—alpha hemolyticus 
type, 2 + 

The final culture proved negative for 
these organisms. 

In the above three instances the di¬ 
agnosis of localized osteomyelitis was 
made. In the following cases none of 
the clinical symptoms of the “dry 
socket” were so well established. Hence 


38 


the diagnosis is merely post-operative 
infection. 

Case 4 

F. C.j 25 year old male, complained 
on the third day following the extrac¬ 
tion of his lower right second molar of 
slight pain in the area. A culture was 
taken, which was followed by debride¬ 
ment, irrigation, and sulfathiazole. At 
the end of 24 hours he said that he no 
longer had any pain. The report of the 
original culture showed: 

1. Streptococcus—beta hemolyticus 
type, 1 + 

2. Streptococcus—alpha hemolyticus 
type, 1 + 

No final culture was taken. 

Ten days later a second tooth, the 
lower left second molar, was extracted 
and this socket, although prophylacti- 
cally treated with sulfathiazole, be¬ 
came infected and slightly painful on 
the 5th day after the extraction. The 
same treatment that had been followed 
for his other tooth was instituted. Pain 
and signs of infection disappeared in 48 
hours. The bacteriological report: 

1. Streptococcus—alpha hemolyticus 
type, 2 + 

No final culture was taken. 

Case 5 

B. D., a 29 year old male, had his six 
lower anteriors extracted at a single 
operation. He complained of a dull 
ache on the third day following the 
extraction but was not seen until the 
7th day, due to circumstances beyond 
his control. On examination pus was 
found in the lower left cuspid socket. 
This socket was irrigated and filled 


with sulfathiazole. He reported that he 
was free from pain and needed no 
more sedative after 24 hours. Cultures 
were not taken in this case. 

Case 6 

K. P., a 24 year old male. On the 
second day after extraction of his lower 
right first and second premolars he 
complained of pain. Examination of 
the sockets revealed the presence of pus 
but no soft tissue swelling. No cultures 
were taken in this case but otherwise 
the treatment was that used in Case 4. 
After 48 hours he no longer com¬ 
plained of pain, nor was there any sign 
of infection. 

In all of the above cases sedation was 
continuously given during treatment. 

V. Summary 

In a group of patients 1,065 teeth 
were extracted j 343 being controls, 381 
being followed by the insertion of sul¬ 
fathiazole into the sockets, and the re¬ 
maining 341 extractions by the placing 
of sulfanilamide into the sockets. Of 
the controls 5 developed post-operative 
infection, an incidence of 1.46%. Of 
those extractions in which sulfathiazole 
was used, only one became infected or 
0.26%. None of the sockets in which 
sulfanilamide was used became in¬ 
fected. 

Sulfathiazole was used in the treat¬ 
ment of the post-operatively infected 
sockets. 

VI. General Comment 

The incidence of infection among our 
controls was 1.46%. Considering the 


39 


Table II 

Treatment and Results 


Patient 

Age 

Tooth 

Pre-treatment 

interval 

Treatment 

Duration of 
symptoms 

Culture* 

Reports 

F.C. 

25 

7 | 

|7 

3 days 

5 days 

culture curettage irri¬ 
gate sulfathiazole 

as above 

24 hours 

24 hours 

strep, alpha i + 
strep, beta i + 

(1) 

strep, alpha 2 + 
(1, 2) 

K.P. 

24 

4,5 

2 days 

as above 

48 hours 

( 3 ) 

B.D. 

29 

13 

7 days 

as above 

24 hours 

( 3 ) 

E.D. 

20 

5 

8 days 

as above 

48 hours 

staph, albus 2 + 
strep, alpha i + 
strep, beta 2 + 

(4) 

P.D.C. 

21 

W 

7 days 

as above sulfathiazole 
also given orally 

72 hours 

strep, alpha 3 + 
strep, beta 2 + 

(4) 

J.R. 

26 

1 . 4 , S 

5 days 

sulfathiazole curettage 
and sulfanilamide 

8 days 

strep, alpha 2 + 
strep, beta 2 + 

(4) 


* Thanks are due Miss Mary Leary for the bacteriological work. 

1. No culture taken at end of treatment. 

2. Previous prophylactic treatment with ulfathiazole. 

3. No culture taken. 

4. Final culture negative. 


systemic condition of many of our pa¬ 
tients this compares quite favorably 
with Archer’s findings, 14 who in 23,886 
extractions found that “alveolalgia” or 
septic socket developed in 226 cases 
00.95%. All of the infected sockets 
occurred in the mandible, which is not 
what Archer found. He reported 79% 
in the mandible and but 21% in the 
maxilla. But our series is much too 
small to warrant a conclusion. 

The data seem to indicate that the 
use of sulfanilamide or sulfathiazole 
prophylactically is advisable, especially 
in mandibular extractions. It is also 
well worth while to use the drugs in 


the treatment of “alveolalgia” or “dry 
socket.” 

Bibliography 

1 Jensen, N. K., Johnsrud, L. W., and Nel¬ 
son, M. C.: Local Implantation of Sulfanilamide 
in Compound Fractures.” Surg. 6:1-12, 1939. 

2 Key, J. A., and Frankel, D. J.: “The Local 
Use of Sulfanilamide, Sulfapyridine, and Sul- 
famethylthiazole.” Annals of Surg . 113:284, 
1941. 

8 Spink, W. W., and Hansen, A. E.: “Sul¬ 
fathiazole, Clinical Evaluation.” J.A.M.A. 115: 
840, 1940. 

4 Long, P. H., and Bliss, E. A.: “Bacterio¬ 
static Effects of Sulfathiazole upon Various Or¬ 
ganisms.” Proc. Soc. Exfer. Biol, and Med. 43: 
324, 1940. 

0 Barlow, O. W., and Homburger, E.: 
“Thiazole Derivatives of Sulfanilamide and Ex- 


40 
































































perimental Beta-Hemolytic Streptococcal and 
Pneumococcal Infections in Mice. Proc. Soc. 
Exfer. Biol, and Med. 43:317, 1940. 

6 Barlow, O. W., and Homburger, E.: “Spe¬ 
cific Chemotherapy of Experimental Staphylo¬ 
coccus Infections with Thiazole Derivatives of 
Sulfanilamide.” Proc. Soc. Exfer. Biol, and 
Med. 42:792, 1939. 

7 Culp, O. S.: “Sulfathiazole Treatment of 
Urinary 7 Tract Infections.” Jour, of Urology 44: 
116, 1940. Reported in Int. Med. Jour. 1940. 

8 Lawrence, D. A.: “Bacteriostatic Actions 
of 3 Thiazole Derivatives of Sulfanilamide 
upon Bacteria in Broth Cultures.” Proc. Soc. 
Exfer. Biol, and Med. 43:92, 1941. 

* BliSs, E. A., and Ott, E.: “Effect of Sul- 
fapyridine, Sulfathiazole, and Sulfamethylthia- 
zole upon Severe Staphylococcal Infections in 
Mice.” Proc. Soc. Exfer. Biol, and Med. 43: 


706, 1940. 

10 Edwards, R. W.: “Dental Uses of Sul¬ 
fanilamide.” J.A.D.A. 27:1394, 1940. 

11 Lockwood, J. S.: “Sulfanilamide in Sur¬ 
gical Infections.” J.A.M.A. 115:1190, 1940. 

13 Spink, W. W., and Paine, J. R.: “The 
Local Use of Sulfathiazole in the Treatment of 
Staphylococcal Infections, Preliminary Report.” 
Minnesota Med. 23:615, 1940. Abs. in Physi¬ 
cian's Bulletin , 1941. 

18 Hubbell, A. O., and Austin, L .T.: “Ex¬ 
traction Wounds and Therapeutic Agents; an 
Experimental Study.” J.A.D.A. 28:251, 1941. 

14 Archer, W. H.: “Analysis of 226 Cases of 
Alveolalgia.” J.D. Res. 18:256, 1939. 

Dental Department, 

St. Francis Hospital, 

Hartford, Conn. 








LOCAL USE OF SULFANILAMIDE AND SULFA- 
THIAZOLE IN EXTRACTION WOUNDS 


Leonard Weiner,* A.B., D.M.D., Tucson, Ariz. 


I N a preliminary report, 1 the data pre¬ 
sented were indicative of the fact that 
sulfanilamide and sulfathiazole should 
be used prophylactically after the extrac¬ 
tion of teeth. However, owing to the 
small number of cases presented, 1,065 
extractions, the data were not conclusive. 
This paper presents additional and sim¬ 
ilar data which, when combined with 
those previously published, permit such 
conclusions. 


the extractions were performed aseptic- 
ally. The rest were carried out under 
field conditions, often in a combat area. 
In the field, antisepsis and cleanliness 
rather than asepsis were the rule. 

4. Owing to primitive conditions and 
the unavailability of laboratory facilities, 
no material for culturing was taken from 
the sockets, clinically diagnosed as in¬ 
fected. Bacteriologic studies could not 
be made. 


Table 1.—Present Data 




Extractions 



Infected Teeth 




Upper 

Lower 

Total 

Upper 

Lower 

Total 

Per Cent 

Control 

220 

247 

467 

0 

5 

5 

1.08 

Sulfathiazole 

222 

211 

433 

0 

0 

0 

0.00 

Sulfanilamide 

198 

242 

440 

0 

0 

0 

0.00 


The methods were those of the prelim¬ 
inary report with the following excep¬ 
tions : 

1. Whereas, in the original experi¬ 
ment, an attempt was made to secure as 
many patients as possible with multiple 
extractions, in this instance no such at¬ 
tempt at selection was made. 

2. Previously, most of the patients had 
entered the hospital because of systemic 
disease rather than oral disease, with the 
result that 25.7 per cent were poor sur¬ 
gical risks. In the present series, almost 
without exception, the patient was in ex¬ 
cellent physical condition. 

3. In this report, only 60 per cent of 

*Captain (DC), AUS. 


A total of 1,340 extractions were per¬ 
formed. Of these, 467 were controls in 
which no sulfonamides were used; 433 
sockets were packed with sulfathiazole 
after the extractions, and 440 were 
packed with sulfanilamide. None of the 
sockets in this series that were given pro¬ 
phylactic chemotherapy became infected 
postoperatively, while five of the control 
sockets became infected, though not in a 
single case did the infected socket reach 
the condition clinically recognized as al- 
veolalgia, or “dry socket.” 

CONCLUSIONS 

1. The use of either sulfanilamide or 
sulfathiazole prophylactically is of defi- 


42 
















nite value in the prevention of postoper¬ 
ative infection in the extraction wound. 

2. Owing to the extremely low inci¬ 
dence of postoperative infection in ex¬ 
traction wounds in the maxilla, none in 


agents should be based on the area of the 
operation, the type of extraction, the 
amount of trauma, the systemic condi¬ 
tion of the patient and the degree of in¬ 
fection present before the operation. 


Table 2.—Present and Previous Data 



Upper 

Extractions 

Lower 

Total 

Infected Teeth 

Upper Lower Total 

Per Cent 

Control 








Previous report 

201 

142 

343 

0 

5 

5 

1.46 

This report 

220 

247 

467 

0 

5 

'5 

1.08 

Total 

421 

389 

810 

0 

10 

10 

1.23 

Sulfathiazole 








Previous report 

169 

212 

381 

0 

1 

1 

0.26 

This report 

222 

211 

433 

0 

0 

0 

0.00 

Total 

391 

423 

814 

0 

1 

1 

0.12 

Sulfanilamide 








Previous report 

177 

164 

341 

0 

0 

0 

0.00 

This report 

198 

242 

440 

0 

0 

0 

0.00 

Total 

375 

406 

781 

0 

0 

0 

0.00 


this series and but one in every 503 ex¬ 
tractions in Archer’s 2 series were infected. 
It is inadvisable to routinely use sulfona¬ 
mides prophylactically in the maxilla. 

3. In every instance, whether in the 
mandible or in the maxilla, the use of 
sulfonamides prophylactically should not 
be routine. Rather, the use of these 


BIBLIOGRAPHY 

1 . Weiner, Leonard: Local Use of Sulfa¬ 
nilamide and Sulfathiazole in Extraction 
Wounds, Preliminary Report. Mil. Surgeon , 
90 : 157 , February 1942 . 

2 . Archer, W. H.: Analysis of 226 Cases of 
Alveolalgia. ]. D. Res., 18 : 256 , June 1939 . 

Station Hospital, Davis Monthan Field. 



43 


















USE OF VINETHENE AS AN ADJUNCT IN 
NITROUS OXIDE-OXYGEN ANESTHESIA 
FOR DENTAL SURGERY 


Neal W. Chilton,* * B.S., D.D.S., New York, N. Y. 


G ENERAL anesthesia for general 
dental practice has been shunned 
by most practitioners as involving 
too much risk, with the feeling that the 
results do not warrant the effort ex¬ 
pended. Too many men simply refer 
cases requiring general anesthesia to spe¬ 
cialists, not realizing that alleviation of 
pain is probably the most important 
single factor in building up a patient’s 
confidence in the dentist. 

We do not say that every patient de¬ 
siring a general anesthetic should be 
given one in a private office without any 
further consideration. Most dental sur¬ 
gical procedures can be performed under 
local anesthesia, but it should be pos¬ 
sible for the adequately trained general 
practitioner to care for those few selected 
cases in which general anesthesia is in¬ 
dicated. Besides the contraindications 
for general anesthesia in office practice, 
which have been so thoroughly discussed 
in many other articles and texts, there 
are several other points that must be 
taken into consideration in the admin¬ 
istration of this type of anesthesia in 
general practice. 

First and foremost, the person admin¬ 
istering the anesthetic should be thor¬ 
oughly trained, both theoretically and 
clinically, in the administration of gen¬ 
eral anesthesia. Since Horace Wells, a 
dentist, introduced general anesthesia, 
we must not lose our heritage and drop 

From the Dental Division, Lincoln Hospital, 
New York City. 

*Instructor in Pharmacology and Thera¬ 
peutics, New York University College of Den¬ 
tistry. 


out of this field because of inadequate 
training. Many dentists have adjacent 
offices, and there is no reason why one 
cannot anesthetize while the other ex¬ 
tracts. Since the general practitioner is 
not so well trained in dental surgery as 
the specialist in this field, he should not 
attempt involved procedures which 
would consume a great deal of time, 
under general anesthesia. The necessary 
equipment for administration, emer¬ 
gencies and recovery should, of course, 
always be present. 

The main reason for this fear of gen¬ 
eral anesthesia in general office practice 
is the untoward reaction of patients 
during the induction phase. Attempts to 
shorten this period, which is the buga¬ 
boo of so many men, have led to the 
so-called rapid-induction method. With 
this technic, the amount of oxygen ad¬ 
ministered is cut down to almost nothing, 
in some cases to nothing. The patient 
then receives ioo per cent nitrous oxide. 
Many men still use this method in spite 
of a great deal of evidence as to the 
dangers involved. Courville 1 has reviewed 
accidents occurring with nitrous oxide- 
oxygen anesthesia and has shown ex¬ 
amples of fatal results with the rapid 
induction technic. True, many men still 
use this method with comparative safety, 
but the absence of ill-effects may be 
ascribed to the short duration of the 
anesthesia. 

Arrowood 2 states, “Since it takes ten 
to fifteen minutes for full saturation with 
a given mixture of nitrous oxide, oxygen 
deprivation during these short pro- 


44 





cedures is not often sufficiently severe to 
be fatal.” But it takes only one min¬ 
ute of oxygen lack to produce histologic 
evidence of permanent damage to the 
brain cells. 8 Although the residual air 
present in the alveoli of the lungs con¬ 
tains oxygen, we cannot afford to work 
with such a low margin of safety as is 
afforded by the so-called rapid-induction 
method. Another point against this 
technic is that a false excitement phase 
may occur during the first stage of anes¬ 
thesia owing to the increased sensation 
of suffocation experienced by the patient. 

Opposed to this method is the so-called 
“slow-induction” technic. With this 
method, an adequate supply of oxygen 
is always being administered to the pa¬ 
tient. Chapman, Arrowood and Beecher 3 
state that “. . . none of our patients re¬ 
tained consciousness beyond 75% nitrous 
oxide (with 25% oxygen), and most of 
them lost consciousness at 60% (with 
40% oxygen).” Arrowood, 2 however, 
says : 

Some, but by no means all, patients can 
be adequately anaesthetized without pre¬ 
medication with this mixture (80% N 2 0, 
20% 0 2 ) for simple extractions, if sufficient 
time is taken to saturate the patient. If this 
cannot be accomplished, nitrous oxide should 
be supplemented with a more potent agent 
in preference to further reducing the oxygen 
content of the mixture. Ether, vinethene, or 
pentothal is suitable for this purpose and 
selection depends upon conditions in each 
individual case. When it is recognized be¬ 
forehand that the patient is likely to be 
resistant, premedication may make the differ¬ 
ence between a stormy course and an un¬ 
eventful one. 

Most dentists are loath to employ 
premedication because of their fear of 
“hangover” effects. We deal with ambu¬ 
latory patients, and depressant drugs are 
not generally used in ambulatory prac¬ 
tice. How, then, can we obtain a safe, 
smooth, yet relatively rapid induction in 
an office patient without premedication ? 
The slow-induction method offers a safe 
and fairly smooth induction, but the 


full effects may not be felt until satura¬ 
tion is reached (after from ten to fifteen 
minutes). Some patients cannot be anes¬ 
thetized with nitrous oxide and oxygen 
alone unless the oxygen supply is cut 
dangerously low. Then, as Arrowood has 
suggested, we must use a more potent 
anesthetic agent as an adjunct. She 
suggests ether, vinethene (divinyl ether) 
or pentothal. The use of ether, because 
of its relatively slow excretion and un¬ 
toward after-effects, is not feasible for 
office patients. Pentothal sodium has 
been recommended for dental office use 
by Hubbell, 4 but the relatively long 
recovery time and incipient dangers asso¬ 
ciated with its use have caused Mecca 9 
and others to discourage its use for gen¬ 
eral office practice. Perhaps in time it 
will be developed into the ideal office 
anesthetic. 

Vinethene, in my opinion, is an ex¬ 
cellent adjunct to nitrous oxide-oxygen. 
It is quick-acting, relatively safe and 
rapidly excreted, with little or no after¬ 
effects. Wellman, Kable and Living¬ 
stone 5 found that only 2.6 per cent of 
patients vomited after its use, in con¬ 
trast to the 57 per cent with ether. 0 
Vinethene is, of course, not perfect. It is 
highly inflammable, cannot be stored in¬ 
definitely, causes increased salivation 
and may be dangerous in the hands of 
the inexperienced. Liver damage has 
been produced experimentally with vine¬ 
thene anesthesia by Goldschmidt et al . 7 
but this has occurred only after pro¬ 
longed anesthesia (two hours or more) 
and in the presence of anoxia. Wellman, 
Kable and Livingstone 5 list the follow¬ 
ing contraindications for vinethene anes¬ 
thesia : “known or suspected hepatic 
damage; operations lasting over thirty 
minutes; the presence of a flame or spark¬ 
ing device; anuria, uremia or marked 
disease of the kidneys; paralysis of the 
vocal cords; ankylosis of the jaws; 
goiter; extensive disease of the lungs; 
diabetes; cyanosis; intestinal obstruc¬ 
tion, and advanced debility.” 



Vinethene has been administered by 
the open drop method at Lincoln Hos¬ 
pital Dental Clinic since 1937 to an av¬ 
erage of fifteen patients a week, mostly 
children. All induction for open drop 
ether anesthesia in the operating rooms 
is carried out by the use of open drop 
vinethene. We have noted a typical 
sequence of clinical signs in induction 
with open drop vinethene. The patient, 
usually a child, breathes the mixture 
according to the anesthetist’s instructions 
for about a minute (“blow it away”). 
He then holds his breath for about ten 
or fifteen seconds. This is followed by a 
short period of slight hyperpnea, after 
which the patient lapses into the smooth 
regular breathing characteristic of vine¬ 
thene anesthesia, third stage, first plane. 
The eyelid reflex is still present at this 
point. The patient is then ready for 
operative procedures. 

For some time now, we have used 
vinethene together with nitrous oxide- 
oxygen for induction and maintenance 
in general anesthesia for exodontia and 
minor oral surgery at the Lincoln Hos¬ 
pital Dental Clinic. We use a Gwathmey 
model machine. This machine is not 
equipped with dials or gages, but with a 
wash bottle into which perforated metal 
tubes are inserted. The number of per¬ 
forations through which the bubbles of 
the gases emerge into the water of the 
wash bottle denotes the proportion of 
the mixture being administered. We start 
with five “holes” of nitrous oxide and 
two and one-half “holes” of oxygen. A 
small wash bottle, into which one third 
of a bottle of vinethene is poured, is 
attached to the system. As the patient 
starts to breathe the nitrous oxide-oxygen 
mixture, the “dial” on the vinethene 
wash bottle is turned on and off two or 
three times, to allow vinethene to bubble 
through the water into the mixture. 
The patient’s reactions are observed. 
One application of vinethene to the mix¬ 
ture is usually sufficient for induction. 


Occasionally, the patient may react to 
this bubbling of vinethene by coughing 
slightly. In this case, we wait a little 
longer before applying the vinethene ad¬ 
mixture. The anesthesia can be main¬ 
tained for as long as is necessary, which 
is usually not more than from ten to 
fifteen minutes, on this mixture of 
nitrous oxide-oxygen, with an occasional 
bubbling of vinethene. 

We have used the same general 
method for major surgical procedures, 
such as appendectomy or hysterectomy, 
for induction in obstreperous patients. 
Here, a Waters’ model is used. Ether is 
placed in the wash bottle and about 15 
cc. of vinethene is placed in the drip 
apparatus. As the mixture of 750 cc. of 
oxygen and 7 liters of nitrous oxide per 
minute is administered, vinethene is 
dropped into this semiclosed system at 
the rate of about 40 drops a minute. 
Induction is usually sufficient by the 
time the vinethene is used up to switch 
to ether without any of the signs of 
pharyngeal irritation which usually ac¬ 
company induction with ether. The in¬ 
duction is smooth, rapid and uneventful. 

SUMMARY 

Most general practitioners are reluc¬ 
tant to employ general anesthesia in 
their offices because of possible untoward 
effects during the excitement stage. 

The rapid-induction method of reduc¬ 
ing these occurrences is too dangerous 
for widespread use. 

The slow-induction method is not al¬ 
ways feasible with obstreperous patients 
without premedication. 

BIBLIOGRAPHY 

1. Courville, C. B.: Untoward Effects of 
Nitrous Oxide Anesthesia. Omaha: Pacific 
Press Publishing Association, 1939. 

2. Arrowood, J. G.: General Anesthesia 
in Dentistry and Oral Surgery. Am. ]. Ortho¬ 
dontics, 29:652-657, December 1943. 

3. Chapman, W. P.; Arrowood, Julia G., 


46 



and Beecher, H. K.: Analgesic Effect of Low 
Concentrations of Nitrous Oxide Compared 
in Man with Morphine Sulfate. /. Clin. 
Investigation, 22:871, November 1943. 

4. Hubbell, A. O.: Pentothal Sodium 
Anesthesia for Dental Surgery in Office Prac¬ 
tice and Control of Recovery Time. Anes¬ 
thesiology, 4 :1 74, March 1943. 

5. Wellman, I. Victoria; Kable, Vera N., 
and Livingstone, Huberta M.: Vinethene for 
Dental Anesthesia. J.A.D.A., 30:1883-1888, 
December 1943. 

6. Waters, R. M.: Present Status of Cyclo¬ 


propane. Brit. Med. /., 2:1013-1017, Novem¬ 
ber 21, 1936. 

7. Goldschmidt, S.; Radvin, I. S., and 
Lucke, B.: Anesthesia and Liver Damage. 
/. Pharm. & Exper. Therap., 59:i-I 4, Janu¬ 
ary 1937. 

8. Thooner, H. W., and Lewy, F. W.: Ef¬ 
fects of Repeated Anoxia on the Brain. J.A. 
M.A., 115:1595-1600, November 9, 1940. 

9. Mecca, A.: Proc. Amer. Soc. Advance¬ 
ment of General Anes. in Dentistry, October 





47 





PHYSICS AND MECHANICS INVOLVED IN 
SERVICEABLE PORCELAIN JACKET 
CROWN RESTORATIONS 


Loren D. Sayre, D.D.S., M.S.D., Chicago, Ill. 


RESERVATION or restoration of 
the integrity of the dental arches is 
of paramount importance if gross 
disfigurement, impaired efficiency, nega¬ 
tive esthetic values and local and sys¬ 
temic disease are to be avoided. Pre¬ 
vention of all dental disease or disorders 
should be the ultimate aim of the dental 
profession, and every form of treatment 
accorded a patient should be preventive 
in character. 

At the present time, we have not 
attained the ideal of complete prevention 
of dental disease, and even if there were 
means whereby the absolute prevention 
of dental caries or irregularities could 
be accomplished, there would always be 
a large percentage of people who would 
not avail themselves of the treatment any 
more than they now avail themselves of 
other established and proved preventive 
measures for other systemic disorders. In 
addition, there are the increasingly large 

Read at the Annual Midwinter Meeting 
of the Chicago Dental Society, February 25, 
1943- 


number of accident and injury cases 
which require restorative measures. 

With this situation in view, the pro¬ 
fession should, while applying all the 
known means of preventing dental 
disease, focus its attention on the best 
possible means of restoration that will 
promote health, comfort, function and 
esthetic appearance. 

A question that might well be asked 
is: “What individual restoration is an 
ideal one, or what qualities go to make 
up an ideal individual tooth restora¬ 
tion?” and “Is there such a method that 
can be universally used in the restoration 
of any or all broken down teeth in the 
absence of disease that warrants the re¬ 
tention of such, a tooth in the dental 
arch?” 

There is such a method. The degree 
of perfection attained is in direct pro¬ 
portion to the accuracy of technic, judg¬ 
ment and skill of the operator, during 
both preparation and restoration. The 
form and color can be so developed that 
the artifice can be detected only by the 



48 








closest inspection. Functional activity 
can be restored and the health of the en¬ 
vironmental tissues can be protected. 
Could anything more be required of any 
restoration? 

The porcelain jacket crown, which is 
such a replacement medium, has the ad¬ 
vantage of being indicated on either vital 
or non-vital teeth, anterior or posterior, 
of either arch. Crown work is rather a 
radical procedure when we consider the 
amount of tooth structure removed dur¬ 
ing preparation, but the results obtained 
more than justify the amount of tooth 
structure lost during the preparation, 
provided it is conservative. 



Fig. i.—Graph showing time and temper¬ 
atures employed in baking specimens. 

The history of a high percentage of 
the teeth which, owing to caries, must 
be replaced by medns of porcelain jacket 
crowns seldom varies, particularly in the 
anterior teeth. The beginning is usually 
incipient decay in the region of the con¬ 
tact point, which, if properly treated 
by means of a gold foil filling with mar¬ 
gins extended to immune areas, would 
call for a small, almost unnoticeable and 
permanent restoration. Such treatment 
is preventive in the highest degree. This 
form of treatment is the exception, 
rather than the rule, at the present time. 


Instead, a cement filling is usually placed 
which, in varying lengths of time, dis¬ 
integrates and washes out, being repeat¬ 
edly replaced with larger and deeper 
fillings of the same kind until one or 
both incisal angles become weakened 
and are fractured off. Some optimistic 
operators even attempt restoration of 
the angles with the same type of filling. 

Obviously, such a practice is wrong, 
and if such possibilities were explained 
to the patient, there would be no ques¬ 
tion as to the type of service which 
would be most acceptable. No individual 
wants temporary work, which must be 
done over at varying intervals, when one 
permanent and satisfactory method is 
available. Incidentally, all of the dam¬ 
age following such a procedure is not 
at the expense of tooth structure, for, as 
fillings wash out, the contact is lost, 
which permits packing of food particles 
into the interproximal space, resulting 
in soft tissue irritation and destruction. 
Then follows loss of the normal inter¬ 
proximal space owing to drifting of 
teeth mesially to take up the space occu¬ 
pied originally by the normally con¬ 
toured tooth. 

This is the history of a large number 
of cases requiring porcelain jacket 
crowns in the anterior part of the mouth, 
a progression of disastrous conditions 
prevention of which in the beginning 
would have made the porcelain jacket 
crown unnecessary, as well as relieving 
the patient of the added trouble and 
expense. 

Many of the profession are under the 
impression that porcelain jackets are 
limited in their application to the six 
anterior teeth, because it is in this loca¬ 
tion that they are most necessary for 
esthetic purposes and most appreciated 
by the patient. In general, they are 
equally useful on any tooth whether 
vital or non-vital, in either arch, where 
access and the operator’s skill are such 
that adequate preparation is possible. 

In particular, they are indicated in 


49 















































(i) teeth badly broken down from 
either accident or caries, (2) hypoplastic 
teeth, (3) peg-shaped lateral incisors, 
(4) badly discolored teeth or teeth with 
mottled enamel, (5) badly eroded or 
abraded teeth and (6) widely spaced or 
poorly alined anterior teeth (within 
reasonable limits), and (7) for increas¬ 
ing the vertical dimension in recon¬ 
struction cases and, (8) with certain 
modifications, as bridge abutments. So 
we see that it is practically universal in 
its application. 


but nothing definite that could be dupli¬ 
cated or proved from the data supplied. 
Nothing of definite value was found re¬ 
garding volumetric change, specific grav¬ 
ity, modulus of rupture, impact tests or 
porosity. This is one reason that porce¬ 
lain has not been more generally used. 
Next, the successful application of porce¬ 
lain jackets requires a thorough knowl¬ 
edge of dental anatomy and histology. 
In no other type of operative procedure 
is this more necessary. In addition, ac¬ 
curate preparation is an absolute necesr 


Table 1 .—Results Obtained from Tests 


Speci¬ 

men 

Method of 
Condensation 

Mix 

Appar¬ 

ent 

Specific 

Gravity 

Mean 

Specific 

Gravity 

Volume 

Shrink¬ 

age 

Mean 

Volume 

Shrink¬ 

age 

Per 

Cent 

Linear 

Shrink¬ 

age 

Modulus 

of 

Rupture 

Mean 

Modulus 

of 

Rupture 

Cl A 

Mechanical vibration 

Wet 

2.39 

2.35 

38.6 

38.1 

12.9 

6,800 

6,950 

Cl B 

Mechanical vibration 

Wet 

2.31 


37.6 


12.5 

7,100 


C 2 

Poured and vibrated 

Very wet 

2.37 

2.33 

37.7 

38.4 

12.6 

7,000 

7,150 

C 2 A 

Poured and vibrated 

Very wet 

2.30 


39.1 


13.0 

7,300 


C 3 

Gravitation 

Wet 

2.33 

2.36 

39.8 

40.5 

13.3 

4,700 

5,300 

C3 A 

Gravitation 

Wet 

2.39 


41.3 


13.8 

5,900 


C 4 

Poured, no vibration 

Very wet 

2.40 

2.38 

42.8 

41.5 

14.3 

4,200 

4,900 

C4A 

Poured, no vibration 

Very wet 

2.37 


40.2 


13.4 

5,600 


C 5* 

Poured, no vibration 

Very wet 

2.29 

2.25 

37.5 

38.5 

12.5 

6,100 

6,100 

C 5 A* 

Poured, no vibration 

Very wet 

2.21 


39.6 


13.2 

6,100 


C 6* 

15-minute vibration 

Medium 

2.20 

2.27 

37.1 

38.2 

12.4 

5,700 

5,050 

C 6 A* 

15-minute vibration 

Medium 

2.35 


39.3 


13.1 

4,400 


C 7 

Vibrated 

Dry 

2.30 

2.28 

34.2 

34.3 

11.4 

6,300 

7,250 

C7 A 

Vibrated 

Dry 

2.26 


34.4 


11.4 

8,200 


C 8 

Poured, no vibration 

Very wet 

2.32 

2.32 

48.2 

47.4 

16.1 

8,400 

7,250 

C 8 A 

Poured, no vibration 

Very wet 

2.32 


46.7 


16.0 

6,100 



*Glycol specimens. 


Why, we might ask at this point, if 
they are so adaptable to the foregoing 
conditions, are they not more generally 
used? There are a number of reasons. 
First, until recently, there was little 
known of the physical properties of por¬ 
celain. In 1934, I began research on 
the physical properties of baked porce¬ 
lain. In a review of the literature, virtu¬ 
ally nothing of a scientific nature was 
found. There were a great many articles 
on porcelain technics and empiric state¬ 
ments regarding the physical properties, 


sity if physical or mechanical failure is 
to be avoided. * 

The technic of preparation is so 
standardized that there is little use of 
repeating it. The main objectives in the 
preparation are the protection of the 
pulp, the peridental membrane and the 
gingival tissues and conservation of tooth 
structure. 

Before any operative steps are taken, 
a careful study must be made of the 
position and size of the pulp, extent of 
caries or depth of previously placed fill- 



50 

























ings, as well as the condition of the apex 
of the root and investing tissues, with the 
aid of recent roentgenograms. Many 
pulps that have the appearance of vi¬ 
tality in an x-ray film will be found to 
be either dead or degenerated when 
tested by means of electrical current or 
thermal change. Accurate studv casts 
will permit a much more detailed ex¬ 
amination of the occlusion than is pos¬ 
sible in the mouth. All of this informa¬ 
tion is necessary for an accurate 
preparation and a minimum of injury to 
both hard and soft tissues, as well as 
a preparation that, owing to its form, 
will meet and supplement the physical 
limitations of the baked porcelain when 
subjected to the stresses and strains of 
mastication. 

Baked porcelain, while an ideal ma- 



Fig. 2.—Ideal preparation embodying 
shoulder cut at right angles to long axis of 
tooth and tapering toward incisal aspect 
approximately i degree. 

terial for restorations in the mouth be¬ 
cause of its esthetic possibilities, the 
tolerance of soft tissue which contacts 
it when the porcelain is highly glazed 
and its insulation properties, has, when 
adequately supported, a high resistance 
to direct force, but low resistance to 
impact force or to torque. The latter 
weakness implies the necessity of proper 
occlusion in alb masticating movements 
to prevent trauma or sudden impact. 

While a certain amount of bulk is 
advisable and desirable, from the stand¬ 
point of color reproduction, it is unwise 
to depend on bulk of porcelain for 
strength. From practical experience, -it 


has been observed that a moderately 
thin, well-supported mass of porcelain 
will tolerate greater stress than will a 
much thicker unsupported mass of the 
same material. 

It is difficult or virtually impossible 
to observe and measure accurately the 
forces acting during mastication. The 
test which most closely approximates 
these forces is the “modulus of rupture” 
test. This is made to determine the force 
in pounds necessary to fracture a trans¬ 
verse section of a material and is used 
principally in testing brick, tile, terra 
cotta and glass. This test combines shear¬ 
ing stress, compressive stress and tensile 
stress all in one operation. The measure¬ 
ments made in inches give a result in 
pounds per square inch required to frac¬ 
ture the specimen. Such a test approxi¬ 
mates the forces in mastication to which 



Fig- 3-—Slightly concave lingual surface of 
preparation area. 

practical porcelain restorations are sub¬ 
jected better than any other static test 
known. 

The size of the specimen used for this 
and other tests as shown in the accom¬ 
panying table was 5X5X31 mm. be¬ 
fore firing, with a volume of 732 cc. 

The tests made upon these specimens 
determined the specific gravity, or den¬ 
sity, the volume and linear shrinkage and 
modulus of rupture. High-fusing porce¬ 
lain was used, all specimens being sub¬ 
jected to the same firing technic. (Fig. 
1 and Table I.) These results indicate 
that, regardless of the method of con¬ 
densation on the consistency of the mix, 
there was less than 0.1 difference in the 


51 











sjx'cific gravity or density, while the 
volume shrinkage varied as much as io 
per cent, depending on the method of 
condensation. So far as the modulus of 
rupture test is concerned, the tests 
showed that the greater the shrinkage, 
the less the transverse strength. 

The condensation or density of the 
unfired mass affects shrinkage during 
firing. Clarke 1 claims that, for prac¬ 
tical work, the amount of linear shrink¬ 
age varies from 9 to 20 per cent. Fel- 
cher 2 states that high-fusing porcelain 
shrinks from 14 to 18 per cent. Gill" 
states that certain high-fusing porcelain 
shrinks from 15..3 to 23 per cent. All 
three authors agree that the degree of 
condensation of the plastic unfired mass 
plays a very important part in the shrink¬ 
age during firing and that condensation 


strains set up in the finished product and 
the form of the prepared tooth that re¬ 
ceives the applied stresses at various 
angles to afford maximum direct resist¬ 
ance, shearing resistance or wedging 
resistance, as well as close adaptation of 
the porcelain to the preparation area. 
Much of the success of the restoration in 
overcoming these conditions lies within 
the control of the operator in so shaping 
the prepared tooth that it offers the 
maximum resistance to and proper dis¬ 
tribution of the applied stresses. 

Resistance and retention form is an 
established principle in any cavity prep¬ 
aration for the reception of any type of 
filling in order to insure permanence of 
the restoration. For the same reasons, the 
preparation of a tooth for the reception 
of a porcelain jacket crown must em- 




portion of preparation, stress being delivered at right angles to preparation area at that surface. 


produced by vibration causes the greatest 
degree of density and consequently the 
least shrinkage. 

The amount of stress, as indicated by 
the modulus of rupture tests conducted 
by Fitzgerald, 4 Moldal 5 and myself, 0 
show that certain high-fusing porcelain 
tolerates from a minimum of 4,200 to a 
maximum of 9,556 pounds per square 
inch transverse stress, the test that com¬ 
bines shearing, tensile and compressive 
stress. This would indicate that, under 
normal conditions, the material would 
have adequate strength. 

There are, however, other conditions 
that affect the strength or durability of 
baked porcelain restorations in the 
mouth: the matter of impact force, 


body principles which will not only pre¬ 
vent the dislodgement or loosening of 
the crown, but will also embrace fea¬ 
tures, in the form of the prepared tooth, 
that will take into consideration the 
limitations of the material used in con¬ 
structing the crown, and, in producing 
this form, combine the resistance and 
retention form to meet and overcome 
the stresses to which the fused porcelain 
restoration will be subjected. 

When considering the resistance form 
necessary for a satisfactory porcelain 
jacket crown, we must be fully aware of 
the limitations of the material, its fri¬ 
ability as compared to any of the metals 
and the effect of both direct and 
leverage forces, which it must tolerate 


52 






it it fulfils its purpose in the dental arch. 

fn considering the friability of porce¬ 
lain, the resistance form of the prepara¬ 
tion area should be such that the maxi¬ 
mum strength ol the porcelain is insured 
under stress. In order to accomplish this 
in the preparation, all planes should be 
so prepared that they receive the applied 
stress at right angles; which means that 
the force in the direction of the long 
axis of the tooth would be received by 
a shoulder cut at right angles to the 
long axis of the tooth. This applies more 
particularly to the labial and lingual 
portions of the shoulder, rather than the 
proximal, as these present sloping sur¬ 
faces. (Fig. 2.) 

The form resistant to direct stress 
applied to the lingual surfaces of the 
upper anterior teeth should present a 




Fig. 5 .—A: Preparation of anterior tooth 
for end-to-end bite. B: Incisal bevel on upper 
central incisor reversed for crossbite. 

broad, slightly concave surface to offer 
the maximum of resistance and support 
of the porcelain. (Fig. 3.) While the 
incisal portion of the preparation area, 
which is subjected to the forces generated 
by the protrusive movement of the man¬ 
dible, can best be made by preserving 
the worn bevel which is found upon the 
natural tooth before the preparation is 
begun (Figs. 4 A, 4 B and 4 C), this 
varies according to the inclination of the 
condyle path and the position that the 
teeth occupy in the opposing arches, 
varying between a deep overbite, end- 
to-end and crossbite. (Figs. 5 A and 5 B.) 

The resistance form of the posterior 
teeth is regulated by the cuspal inclina¬ 
tions. Here also, the natural wear in¬ 


fluences the preparation, varying from 
acute to obtuse angles upon the occlusal 
surface. (Figs. 6 A and 6 B.) In general, 
if an even thickness of tooth structure is 
removed from the occlusal surface of the 
posterior teeth to allow for an adequate 
thickness of porcelain, we can be as¬ 
sured that the resistance form of that 
occlusal surface will be correct. The 
amount and location of tooth structure 
removed should be determined with the 
idea of supporting the porcelain, leaving 
as little unsupported or overhanging 
porcelain as is possible, rather than de¬ 
pending on the bulk or mass of material 
for strength or resistance to stress. In 
short, the resistance form is the shape or 
form given to a tooth preparation that 
will enable it best to withstand the 
stresses of mastication. It is important 
in direct ratio to the exposure of the 




Fig. 6 .—A: Preparation where little occlu¬ 
sal wear has taken place, cusps are high and 
grooves are deep. B: Preparation of posterior 
tooth where occlusal surface is worn to prac¬ 
tically flat plane. 

crown to the force exerted in bringing 
the teeth into any of the movements or 
positions during occlusion. 

Retention form is so closely associated 
with resistance form that there is little 
difference so far as the preparation is 
concerned. Convergence toward the in¬ 
cisal or occlusal surface should not be 
more than 1 degree from the right angle 
shoulder at the gingival surface ; merely 
enough to allow removal of the impres¬ 
sion of the preparation area without dis¬ 
tortion. If the shape of the preparation 
area results from removal of an even 
thickness of tooth structure or its equiva¬ 
lent in a gold casting, this form will be 




53 







adequate to prevent a tendency toward 
displacement by rotation, which would 
certainly be the case if the preparation 
area were cylindrical or cone-shaped. 

Although it must be recognized that 
there are variations from the foregoing 
to meet certain definite requirements, the 
farther we depart from the ideals before 
mentioned, the more we court disaster. 
There are a few variations that merit 
mention: first, the shoulderless crown, 
used principally in the lower central and 
lateral incisor locations and occasionally 
on bicuspids where the gingival portion 
of the root is extremely narrow mesio- 
distally and presents concave surfaces 
upon these areas. Coupled with a well- 
crowned coronal portion of the tooth, it 
presents a very serious problem in a con¬ 
ventional type preparation without in- 




Fig. 7.—A: Preparation for lower anterior 
tooth in younger person when gingival por¬ 
tion of root is constricted. B: Preparation for 
upper bicuspid with root constricted mesio- 
distally. 


volvement of the pulp. In such cases, the 
crown portion of the tooth is tapered at 
a 1 degree angle to the long axis of the 
tooth to a point just beneath the free 
gingival margin, as much tooth structure 
as possible being preserved mesiodistally 
to protect the pulp as well as to support 
the porcelain, the feather edge of which 
extends just beneath the free gingival 
margin. 

From the standpoint of resistance or 
retention, the shoulderless crown can 
meet these requirements, as explained by 
Grubb 7 : 

Considered from the viewpoint of func¬ 



tion alone, a jacket crown in a preparation 
without a shoulder on any surface offers 
ample resistance. There is less overhang of 
unsupported porcelain. Moreover, the pres¬ 
sure developed by a slight deformation of 
the prepared tooth due to the compressibil¬ 
ity of the dentin would be transmitted to 
and be absorbed by the entire crown. 

However, from the standpoint of fu¬ 
ture disease of the surrounding soft tis¬ 
sue, this type of preparation is far from 
ideal. A feather edge of porcelain is 
always sharp and rough and, owing to 
the inherent qualities of the porcelain 
material, these thin edges are friable and 
easily fractured, sharp, angular irritating 
surfaces resulting which not only damage 
the soft gingival tissue, but expose to 
the fluids of the mouth a portion of the 
dentin of the prepared tooth. 



Fig. 8.—A: Gold casting that prevents un¬ 
supported bulk of porcelain at proximal 
aspect. B: Insufficiency of tooth structure re¬ 
maining to properly support porcelain. The 
tooth must be built up with gold casting to 
ideal form. 


On the other hand, if a blunt, rounded 
edge is made, contour of the gingival 
portion of the crown is exaggerated, and 
this is damaging to the gingival tissues 
and, in addition, adversely affects the 
appearance by providing an inharmon¬ 
ious tooth form. 

There are, perhaps, cases wherein the 
conformation of the crown and root por¬ 
tion of the tooth is such in relationship 
to the pulp that it would be advisable 
to have a shoulderless portion upon the 
prepared root: This would be true in 
a younger person in whom the pulp is 
extremely large and the mesiodistal di- 


\ 


54 


















amctcr of the root portion is extremely 
narrovv r . In such a case, the prepared 
tooth could have a properly prepared 
shoulder on the labial and lingual as¬ 
pects, tapering out and terminating just 
beyond the angles proximally. (Figs. 
7 A and 7 B.) While such a preparation 
is not ideal, it is protective to the pulp 
of the tooth and, at a later date, when 
the pulp has receded sufficiently to per¬ 
mit the formation of a proximal shoul¬ 
der, such a preparation should be made, 
the original restoration being considered 
as a temporary expedient. 

So far, we have considered teeth hav¬ 
ing abundant tooth structure in which 
to make an ideal preparation. Unfor¬ 
tunately, there is not always a sufficient 
amount of tooth structure remaining 



Fig. 9 .—Gold core made to build up pulp¬ 
less tooth to ideal form to support porcelain 
and prevent fracture of root due to leverage. 

after all carious and weakened areas 
have been removed to permit such a 
preparation, and if we would have ade¬ 
quate support for a jacket crown, it is 
necessary to reproduce the lost tooth 
structure by means of a gold casting, 
regardless of whether or not it is a vital 
or pulpless tooth. If the tooth is vital, 
the preparation is made so that a wax 
pattern (Figs. 8 A and 8 B) of proper 
form and retention can be made and 
duplicated in gold. In pulpless teeth, a 
gold core with a dowel extending into 
the root canal for retention can be made, 
the prepared area being formed in such 
a manner as to prevent splitting of the 
root under stress. (Fig. 9.) These are 
cemented to place and treated, so far as 


further construction is concerned, as 
tooth structure. 

This method of making use of a gold 
core can also be used in certain cases 
(Figs. 10 A and 10 B) wherein, for es¬ 
thetic effects, it becomes necessary to use 
a jacket crown as a bridge abutment. 
The gold core can be constructed with 
a proximal extension which will afford 
a soldering joint for the bridge attach¬ 
ment. 

While, from a mechanical standpoint, 
it has been shown that proper form 
must be obtained in the preparation to 
prevent overhanging or an unsupported 
bulk of porcelain to insure a durable and 
satisfactory crown, it must be kept in 
mind that handling of the porcelain 
material itself during the building up of 


\ 



Fig. 10 .—A: Labial view of gold casting 
with proximal extension for soldering, making 
possible use of porcelain jacket as bridge 
abutment. B: Proximal view of casting. 

the porcelain plays an important part in 
the strength of the finished crown. 

There has been a general belief in the 
profession that there is a great variation 
in the strength of high, medium and low 
fusing porcelains. This has not been 
borne out by the investigations of Fitz¬ 
gerald, 4 who found that in strength each 
was comparable to the others, although, 
in general, the high fusing porcelains 
have the highest modulus of rupture, and 
the low fusing, the lowest modulus of 
rupture; but the variation was so snjall 
that the indications were that it is not 
necessary to use high fusing porcelain to 
have adequate strength for restorations. 

There are other factors in the strength 


55 

















of the finished porcelain product besides 
the fusing point. The constituents of 
porcelain include flux, which has the 
lowest fusing point of all of the ingredi¬ 
ents and which, upon fusing, forms a 
bond that unites the higher fusing ma¬ 
terials. Searle 8 writes : 

The nature and amount of the bond 
largely determines the strength of ceramic 
materials at various temperatures. In con¬ 
junction with the bond, particle size and 
shape are to be considered. In ceramic ma¬ 
terials, the maximum strength is obtained 
by the use of irregular, angular grains of 
numerous sizes which interlock freely. 

Clark 1 found that the texture and 
strength of porcelain was at its greatest 
at the point where vitrification is com¬ 
plete. In order to produce the necessary 
translucency and glaze to satisfy esthetic 
requirements, and a non-irritating sur¬ 
face in contact with the soft tissue, we 
must carry the fusion beyond the point 
of complete vitrification. 

Fusing of porcelain permanently af¬ 
fects its physical properties; that is, it 
does not return to its original condition 
upon cooling, as metals do. Metals can 
be fused repeatedly and, upon cooling, 
each time revert to their original condi¬ 
tion. Porcelain, subjected to repeated 
firing, begins with the condition that 
was produced by the previous firing and 
progresses from that point. With each 
successive firing or with increases of 
heat, the pores or blebs enlarge, owing 
to the formation of gases; the trans¬ 
lucency increases; the strength de¬ 
creases and a colorless, glassy, highly 
vesicular mass results, tending toward 
the spherical. Therefore, if it were pos¬ 
sible to produce an accurately fitting and 
contoured crown in one bake, stronger 
restoration would result than one sub¬ 
jected to several firings. There is one 
other consideration which, if neglected, 
often results in failure of the crown. 
That is the provision necessary to ac¬ 
commodate the crown for the normal 
occlusal wear. 


Contact with highly glazed porcelain 
causes almost no wear or abrasion upon 
human enamel. There is always occlusal 
or incisal wear on natural teeth, at vary¬ 
ing rates in the mouths of different per¬ 
sons. If no provision is made upon the 
glazed porcelain for restoration of the 
wear, it soon results in traumatic occlu¬ 
sion with a labial displacement of the 
entire root and crown in the case of the 
upper anterior teeth, or a fracture 
of the crown due to impact force, or a 
breaking down of the investing tissues. 

All of the foregoing results can be 
avoided by etching slightly the highly 
glazed portion of the crown that con¬ 
tacts the opposing teeth during any of 
the movements of mastication as dis¬ 
closed by the use of carbon paper. This 
etched surface, in contrast to highly 
glazed surfaces of porcelain, is highly 
abrasive and will cause wear of the 
opposing teeth equal to the wear of 
attrition upon the the natural teeth in 
the arch. These areas, incidentally, are 
the only surfaces of the entire crown 
where unglazed porcelain is permissible. 

If unglazed porcelain touches the ap¬ 
proximating teeth, the interproximal 
wear, which is constantly progressing, 
soon destroys the normal contact point, 
rendering it flat and allowing the impac¬ 
tion of fibrous foods, with its attendant 
damage to the interproximal tissues. If 
unglazed or etched porcelain touches 
the soft tissue of the gingivae, an irrita¬ 
tion and inflammation results, and if the 
labial or buccal glaze is destroyed, the 
translucency and color are destroyed and 
there is an accumulation of stain and 
debris. 

I o those who are seriously interested 
in the improvement of their knowledge 
and technic upon this subject, I can only 
recommend that they read and reread 
the literature I have referred to in this 
paper, and to those who are inclined 
toward research, I can suggest that there 
still exist a great number of unsolved 
problems regarding baked porcelain. 


56 


BIBLIOGRAPHY 

1. Clark, E. B.: Manipulation of Dental 
Porcelain. J.A.D.A., 22:33-40, January 1939. 

2. Felcher, F. R.: Art of Porcelain in 
Dentistry. St. Louis: C. V. Mosby Co. 

3. Gill, J. R.: Methods and Results in 
Condensation of Dental Porcelain. J.A.D.A., 
19:1147-1152, July 1932. 

4. Fitzgerald, P. A.: Comparison of Phys¬ 
ical Properties of High, Medium and Low 
Fusing Dental Porcelains. Master’s Thesis, 

1936. 


5. Moldal, O. H.: Physical Properties of 
Opaque Porcelain. Master’s Thesis, 1938. 

6. Sayre, L. D.: Effects of Varying Manip¬ 
ulations upon Certain Physical Properties of 
Dental Porcelains. Master’s Thesis, 1936. 

7. Grubb, H. D.: Basic Procedures Essen¬ 
tial for Successful Porcelain Restorations. 
Proc. D. Centenary Celebration, March 1940. 

8. Searle, A. B.: Chemistry and Physics of 
Clays and Other Ceramic Material. New 
York: D. Van Nostrand Co., 1924. 

30 North Michigan Avenue. 



57 










A NEW TYPE OF PORCELAIN BRIDGE AND THE 
TECHNIC FOR ITS CONSTRUCTION 


Arthur F. Schopper, D.D.S., Kansas City, Mo., and 
Jacob A. Saffir, D.D.S., Kew Gardens, L. I., N. Y. 


F OR more than sixty years, porcelain 
has been employed in dental bridge 
prosthesis. A period of such length 
has provided an unusual opportunity to 
study and evaluate this material. 

A number of years ago, Albert L. Le- 
Gro wrote, “The practitioner of today is 
gradually coming to realize that porce¬ 
lain in dentistry, aside from being ex¬ 
ceedingly artistic, is rapidly taking its 
rightful place as a restorative material, 
second to none.” 1 

Recently, Stanley D. Tylman 2 compe¬ 
tently observed that “the biological com- 
patability and the esthetic qualities of 
glazed porcelain have directed the atten¬ 
tion of the dental profession for many 
years toward the possibility of construct¬ 
ing serviceable bridges made entirely of 
baked porcelain.” 

The porcelain bridge has always been 
popular with men who understood its 
indications. In the main, there are two 
types of porcelain bridge in use. One, 
of all porcelain, has its place where the 
span is short and biting conditions are 

Read at the Eighteenth Annual Midwinter 
Meeting of the Chicago Dental Society, Feb¬ 
ruary -22, 1944. 


extremely favorable. The second, used 
where the span is longer or the biting 
more severe, is the reinforced porcelain 
bridge, built around a strong metallic 
bar. This type, by far the most practical, 
when used under proper conditions, has 
proved stronger and more satisfactory. 

Despite the frequent indications for its 
use and its many well-known advantages 
over other prostheses, the reinforced 
porcelain bridge, is not commonly em¬ 
ployed. Perhaps this is as much due to 
the specialized skill and the amount of 
laboratory time required for its construc¬ 
tion as it is to the expense involved. Also 
to be taken into consideration are the 
work and expense that face the dentist 
and the patient when a broken pontic is 
to be replaced, since this procedure ne¬ 
cessitates the removal of the bridge and 
often the remaking of all the pontics. 

The advent, about three years ago, of 
a pin pontic tooth with a porcelain in¬ 
cisal edge and gingival border made pos¬ 
sible the construction of a porcelain 
bridge closely similar, in esthetic values, 
to the all-porcelain reinforced bridge and 
with the following decided advantages 
over it: 


58 








1. Broken pontics can be easily re¬ 
placed without necessitating the removal 
of the bridge, as new pontics can always 
be ground in and fitted to the bridge 
structure. 

2. Special skill in ceramics is no longer 
required because of the ease of assembly 
and construction by the use of these 
pontics. 



Fig. i.—Lingual and proximal view of 
pontics, showing pin recess, root end (left) 
and saddle (right) type. 



jrjg 2 .—Model showing six-tooth anterior 
bridge using porcelain veneer jacket crowns 
as abutments; also impression for construction 
of all-veneer bridge. 

< 

3. The results are just as esthetic and 
yet the cost no longer is a factor. 

4. If the case indicates, the dentist can 
have the biting portion of the pontic re¬ 


inforced with strong metal, which will 
add protection to the porcelain in this 
region. 

5. The teeth may be glazed or changed 
in any way, individually, and the entire 
bridge is not subjected to the danger of 
the furnace for any adjustment to one of 
its pontics. 

6. The pontics can be replaced even 
after the bridge has been in the mouth 
for several years, should the color, size or 
any other condition demand it. 



Fig. 3.—Model with abutment in place 
using porcelain veneer crowns as abutments. 



Fig. 4 .—Labial view. The teeth chosen 
for the case were the right width, but longer 
than in the completed case. 


7. Replacements and repairs can be 
made by a dentist wherever teeth are 
purchasable; thus the bridge does not 
have to be sent for these services to a city 
where there is a competent ceramist. 

The teeth described in this paper, for 
pontic uses, are all porcelain, except for 
the two platinum pins in a recess on the 
lingual surface. (Fig. 1.) This recess is 


59 












































above the incisal edge of the tooth, to 
leave a translucent incisal edge in the 
finished bridge, and is a short distance 
below the gingival border of the lingual 
surface, so that when the casting, which 
will serve as a reinforcement, is made, it 
will not impair the translucence of the 
tooth any more than the reinforcing bar 
which is present in all reinforced porce¬ 
lain bridges. 

We see, therefore, that in this bridge 



Fig. 5 .—Lingual view of teeth chosen for 
case, showing ample room to grind root ends 
for adaptation. 



Fig. 6 .—Teeth arranged and held in place 
by sticky wax, while plaster index is made 
on labial aspect. 


the reinforcing bar is on the lingual as¬ 
pect instead of being embedded within 
the porcelain as it is in the all-porcelain 
reinforced bridge. 

Chosen here for illustration is a case 
requiring the replacement of the central 
and lateral incisors, using the cuspids for 
abutments. This is shown in Figure 2, 
which also shows the impression of the 


case. Porcelain veneer jacket crowns 
were used as abutments in this case and 
these are shown on the model in Figure 3. 

In choosing pontics, the procedure is 
as follows: 

After the width is determined, the 
length is so approximated that one will 
not have to cut away much or any of 
the translucent incisal tip. The teeth 
chosen for this case are shown in Figure 

4 - 



Fig. 7 .—Labial index in place holding pon¬ 
tics in correct position while being waxed on 
lingual aspect. 



Fig. 8 .—Reinforced pontics waxed and 
ready for casting; showing two central in¬ 
cisors with added reinforcement. 

Second, one should so choose the 
length that the pins will come at about 
the cingulum area of the tooth. This 
may require some adjustments of the root 
end area of the pontic to permit proper 
adaptation of the root end. In Figure 5 
is shown the lingual aspect of the teeth 
chosen and illustrated in Figure 4. 

It is best to select a facing from 1 to 2 


60 















mm. longer than is necessary, to permit 
a good gingival adaptation, as is shown 
in Figure 4. After the teeth have been 
properly adjusted gingivally, their incisal 
edges should be in the approximate posi¬ 
tion that they will hold in the finished 
bridge and they also should be prepared 
on both the mesial and the distal aspect 
to assume, in all respects, their final 
shape and form. 

The preparation on the lingual surface 
of the pontic comprises the beveling of 
all the margins. Where it has been ascer¬ 
tained that there is to be undue stress on 
the incisal edge, a triangular groove hav¬ 
ing a slightly flattened apex is cut in the 
center of the lingual surface starting 
from the incisal portion of the pin re¬ 
cess and continuing incisally to within 



Fig. 9 —Cast backings showing slot cut to 
connect with pin holes; also lingual castings 
for abutments with pin holes to accommodate 
porcelain facing. 

from 0.5 to 0.75 mm. of the incisal edge. 

It can be seen that the casting which 
extends up .into this groove, as well as the 
extensions upward along the mesial and 
distal bevels, will act as a guard for the 
incisal portion against stresses which por¬ 
celain, by itself, usually does not have 
the strength to withstand without frac¬ 
ture. 

One must be sure to use for backing 
material a suitable extremely hard cast¬ 
ing gold. Such gold is generally labeled 
by the manufacturer “extra hard,” hav¬ 
ing a Brinell hardness from 148 upward 
when bench cooled. 


After the lingual portion has been pre¬ 
pared, the teeth are completed. The next 
step is to properly aline the teeth on an 
articulated model of the mouth, then to 
secure the teeth to each other and to the 
model on the lingual aspect by any of the 
well-known means, such as sticky wax, 
soft wax or modeling clay. 

While teeth are thus being held, as 
shown in Figure 6, a small amount of 
plaster of Paris is placed on the labial 



Fig. 10 .—Labial index in place with pon- 
tics, and castings in place with lingual index 
relined for soldering. 



Fig. 11 .—Pontics and abutments on model 
soldered except in median line, which is 
soldered later. 


surfaces of the teeth and on a small labial 
portion of the model, including the labial 
portion of the cuspids, so as to furnish, 
when set, a means for accurately holding 
the teeth in their proper places on the 
model. This step is shown in Figure 7, 
and this is the place where the teeth will 
be in the finished case when placed in 
the mouth. 










This holding or retaining means of the 
teeth is hereafter referred to as an index, 
for it enables the proper indexing of the 
teeth in respect to the model. 

We can now work freely on the lingual 
portion and proceed by treating the 
lingual recesses in the porcelain with a 
separating medium which will not per¬ 
mit wax to stick to the porcelain, inas¬ 
much as we are to take wax impressions 
of the lingual recesses on these pontic 
teeth. It is not considered advisable to 



Fig. 12 —Labial view of completed bridge. 



Fig. 13 .—Labial view of practical case re¬ 
placing upper right central and lateral in¬ 
cisors. 


make more than two backings in one 
casting. In fact, it does not require much 
more time to construct individual back¬ 
ings. 

After the wax has been placed in the 
recesses, it is properly carved to repro¬ 
duce the form desired for the lingual 
surface, as shown in Figure 8. It is then 
removed, invested and cast. 


There are various methods of repro¬ 
ducing the pin holes during the casting 
operation. The wire in a No. 3 paper clip 
is of the same diameter as the pin and 
the wire in a No. 4 Puritan bank pin is 
of the same gage as the pin. Either of 
these can be placed in the hole, and, 
after casting, be removed by dissolving 
in nitric acid. 

A carbon point may also be used for 
this purpose, but this is the least desirable 
of all of the methods because it fre¬ 
quently leaves gas bubbles in the gold 
around the carbon points. The preferred 
method is to carve a small groove on the 
gingival aspect of the wax, deep enough 
to reach the ends of the pin holes, as 
shown in Figure 9. 



Fig. 14 .—Lingual view of practical case re¬ 
storing upper right central and lateral in¬ 
cisors with added reinforcements of pontics. 

This procedure gives three worth while 
results : 

First, the investment can run right 
through the pin holes, with practically 
no danger of trapping air, and with a 
good opportunity for a fine casting of the 
pin holes. 

Second, there is a slight saving in gold. 

Third, proper cementing is simpli¬ 
fied and more or less assured because 
the cement runs right through these 
holes. 

One of the difficulties in properly ce¬ 
menting this type of pontic where no 
opening into the pin holes has been 
created lies in failure to force the air out 


62 
























of the pin holes, thereby allowing the 
cement to completely fill the pin holes. 

Another method, of course, of con¬ 
structing this type of bridge allows the 
pins to go right through the backing and 
come out on the lingual surface. This 
method also permits proper investment 
and simplified cementing and has its ad¬ 
vantages in these respects. 

The backings, having been cast, are 
fitted to the pontics. Then, by use of the 
index again, the pontics are realined, as 
shown in Figure io. 

At this point, it is necessary to take a 
lingual impression of the bridge with the 
backings in their proper position, pour 
this impression with soldering investment 
and proceed with the soldering opera¬ 
tion. 

It is preferable not to solder the entire 
bridge in one operation, but to solder it 
in small sections, making new indices 
after each soldering operation. It is also 
desirable to solder first the pontics near¬ 
est to the abutments and then the inter¬ 
mediate pontics. In Figure 11 are shown 
the central and lateral pontics soldered 
to an abutment. They will next be 
soldered to each other. 

Although the entire bridge may be 
soldered on the model, it is preferable to 
leave one joint open until the final fitting 
in the mouth, where an impression is 
taken and poured in soldering invest¬ 
ment. When the bridge is then finally 
soldered, one is assured of the maximum 
in accuracy of assemblage. 

When soldered and assembled, the fin¬ 
ished bridge, as will be noted, has the 
same appearance as in Figure 6, when 
the teeth were completed and assumed 


the shape and position that had been 
anticipated for the finished bridge. 

Figure 12 shows the completed and as¬ 
sembled bridge off the model. Figure 13 
shows the labial appearance of another 
bridge, using these pontics and this type 
of construction in the mouth of a patient 
in whom the right central and lateral 
incisors were restored. ‘Figure 14 shows 
the lingual aspect of this same bridge. 

The same indications and contraindi¬ 
cations that are present in porcelain 
bridge work in general are applicable to 
this type of bridge as well. For example, 
a very close bite, especially if it is an end- 
to-end bite, is frequently a contra-indica¬ 
tion. If employed in the average mouth, 
however, where conditions are fair, a 
completely satisfactory bridge, both es- 
thetically and functionally, can be pro¬ 
duced. 

Upon viewing the esthetic and satis¬ 
factory results with porcelain bridge 
work, one must concur with the observa¬ 
tion of J. L. Loop, 8 professor of ceramics 
at the University of Southern California, 
that “restorative dentistry which, after 
all, comprises by far the major portion 
of the dentist’s ministrations, finds its 
most finished form of expression in por¬ 
celain work.” 

BIBLIOGRAPHY 

1. LeGro, A. L.: Ceramics in Dentistry. 
Ed. 2. New York: Dental Items of Interest 
Publishing Co., 1931. 

2. Tylman, S. D.: Theory and Practice of 
Crown and Bridge Prosthesis. St. Louis: C. V. 
Mosby Co., 1940. 

3. Loop, J. L.: Porcelain in Dentistry. Un¬ 
published data. 

914 Professional Building. 

119 Quentin Street. 


63 



COMPLETE DENTURE IMPRESSIONS BASED 
UPON THE ANATOMY OF THE MOUTH 


Carl O. Boucher,* D.D.S., Columbus, Ohio 


T HE objectives of complete denture 
impressions are : (i) retention, (2) 
stability, (3) support, (4) esthetic 
values and (5) preservation of the al¬ 
veolar ridges. Success in attaining these 
objectives depends on the dentist’s knowl¬ 
edge of the anatomy of the mouth, and 
his skill in the use of an impression tech¬ 
nic to establish the desired relationship 
between these objectives and the ana¬ 
tomic structure of the mouth. 

Retention of a denture is based on 
its resistance to forces that tend to re¬ 
move it from the normal close contact 
with the mucous membrane. It is the 
most spectacular and probably the least 
important of the objectives. It is spec¬ 
tacular to pull on an upper denture with¬ 
out its becoming loose. Likewise, it is 
good showmanship to be unable to dis¬ 
lodge the lower denture by means of an 
instrument placed against the lower in¬ 
cisor teeth. But these are not functional 
forces. A denture that would withstand 
this kind of test might be a failure under 
functional conditions. Also, it might not 
meet the other objectives of complete 
dentures. Overextension or an extremely 
tight peripheral seal would develop this 
type of retention. Retention attained 
by these means would be only temporary. 
Stability and support would be lost with 
the destruction of the supporting struc¬ 
tures. Esthetic values would be lost and 
the retention itself would become ineffec¬ 
tive when the mouth is open wide or 
when the jaw is moved from side to side 

*Professor of prosthetic dentistry, Ohio 
State University. 


or the tongue is manipulating food in 
the mouth. 

Retention is attained by the forces of 
adhesion, cohesion and atmospheric pres¬ 
sure and the plastic molding of soft tissues 
around the polished surfaces of the den¬ 
tures. Adhesion and cohesion are effec¬ 
tive when there is perfect apposition of 
the impression surface of the denture to 
the mucous membrane surface. These 
forces lose their effectiveness if there is 
any horizontal displacement of the den¬ 
tures that breaks the continuity of this 
contact. Atmospheric pressure is effec¬ 
tive primarily as a rescue force when ex¬ 
treme dislodging forces are applied to 
the denture. It depends on a perfect 
peripheral seal to keep the pressure ap¬ 
plied on only one side of the denture. 
The presence of air on the impression 
surface would neutralize the pressure of 
the air against the polished surface. Since 
each of these forces is directly propor¬ 
tional to the area covered by the den¬ 
tures, the dentures should be extended 
to the limits of the oral cavity. 

The plastic molding of the soft tissues 
around the polished surfaces of dentures 
helps to perfect the peripheral seal. Also 
it forms a mechanical lock at certain 
locations on the dentures, provided these 
surfaces are prepared for it. This lock is 
developed automatically and without ef¬ 
fort by the patient if the impression is 
built with an understanding of the ana¬ 
tomic possibilities. An example of this 
lock can be seen at the distobuccal angle 
of the lower denture, where the suctoral 
pad in the cheek folds over it. 


64 






Stability is based on the resistance to 
horizontal movement of the denture. Re¬ 
tention is lost when the limit of stability 
is exceeded by forces applied to the den¬ 
ture. Horizontal movement of the den¬ 
ture takes the denture out of contact 
with the mucous membrane and breaks 
the peripheral seal. Therefore, it may be 
said that stability is more important than 
retention. Stability is necessary to resist 
the forces of occlusion, both centric and 
eccentric. It is attained by utilizing the 
surfaces of the maxilla and mandible 
that are at or near right angles to the 


Support for a denture is based on the 
resistance to forces at right angles to the 
occlusal surface of a denture. A favor¬ 
able supporting structure is one that does 
not permit an appreciable change of 
position of the denture under varying 
pressure. The quality of the support de¬ 
pends on the thickness of the soft tissues 
over the bone and the way in which the 
impression materials are carried against 
them. 

The esthetic value, or appearance, of 
the denture is dependent in no small way 
on the impressions. The denture borders 



jrjg, I# _Plaster wash impression taken in modeling compound tray. The maxillary groove 

(1) gives support for the denture and is recorded with the tissue at rest. The median groove 

(2) and the incisive fossa (3) are to be relieved in the denture to balance pressures and protect 
the blood and nerve supply. The maxillary tubercular fossa (4), together with areas on the 
buccal and lingual aspect of the maxillary groove (1), gives lateral stability. The masseter groove 
(5) provides space for the masseter muscle and ramus in function. The labial notch (7) and 
buccal notch (8) provide space for the labial and buccal frenula (9)* The buccal flange fills 
the buccal vestibule, attaining maximum tissue coverage, and together with the labial, flange 
(10) pterygomaxillary postdam (11) and the palatal postdam (12), forms a complete peripheral 
seal. , The labial flange 10) is adjusted for thickness to support the lip for improvement of the 

appearance. 


occlusal plane. These surfaces might not 
be at a favorable angle, and the soft tis¬ 
sue over them might be too soft in many 
cases for ideal results. It is the dentist’s re¬ 
sponsibility to know where these areas are 
and how to make the best use of them. 


support the reflection tissues when neces¬ 
sary. The shape of the mouth and the 
fulness of the lips depend on the proper 
support of these tissues at the periphery, 
and by the thickness of the labial flange. 
The effectiveness of the peripheral seal 


65 








and stability is reduced if the impression 
is constructed with a labial flange that 
is too thick. The flange must then be 
reduced in thickness, the tissues thus 
being permitted to drop back away from 
the denture. Overextension of an im¬ 
pression will reduce the amount of verti¬ 
cal opening possible for a case. Then 
when overextension is corrected, the tis¬ 
sues will not be properly supported and 
the vertical dimension will be reduced 
too much. 

The preservation of the alveolar ridge 
is the most important objective of im¬ 
pressions for dentures. The destruction 


than impressions in this tissue loss, or 
softening, but improper placement of 
pressure by an impression can interfere 
with the blood and nerve supply to the 
tissues; and will cause its destruction. 

The foregoing remarks briefly outline 
some of the problems involved in devel¬ 
oping an impression technic. How these 
objectives are to be attained will be in¬ 
dicated. (Figs. 1-2.) 

Effective adhesion and cohesion can be 
attained for an upper denture by use 
of a plaster wash impression, if the 
wash is taken in a tray that properly 
supports the plaster. The tray must carry 



Fig. 2.—Anatomy of upper jaw. For retention, the denture is limited by the labial frenum, 
labial reflection, buccal frenum (i), buccinator muscle (2), masseter muscle (17), ramus, ham- 
ular notch (7) and vibrating line (9). Stability is attained by contact with the buccal and 
lingual side of the alveolar ridge when the median raphe (15) is relieved. The lip must be sup¬ 
ported by the labial flange for the sake of appearance. The blood supply is protected by relief 
of the incisive foramen (16) and by the thickness of the palatal glands (14) covering the greater 
palatine foramen (12). 


of ridges will carry with it the loss of 
retention, stability and support of the 
dentures and will ruin the finest esthetic 
effect of the restoration. Discomfort and 
inefficiency will replace the comfort and 
efficiency that were attained along with 
the other objectives, when the ridges 
shrink away. There may be factors other 


a minimum bulk of plaster into a definite 
contact with the tissue. Excessive bulk 
of plaster causes distortion through its 
expansion. The tray must not contact 
the tissue as it carries the plaster to po¬ 
sition, because this would distort the 
tissue surface. This distortion would 
cause injury to the tissue or soreness by 


66 






interfering with its blood supply. More¬ 
over, the distorted tissue would tend to 
resume its normal form, thus exerting a 
force to dislodge the denture. From this, 
it can be seen that it is desirable to 
record the tissue surface in its relaxed 
form. 

A good peripheral seal may be obtained 
in plaster if it is properly supported by a 
tray, which must have sufficient width 
at the periphery to support the plaster 
and must have sufficient height to carry 
it to within 1.5 mm. of the reflected tis¬ 
sues, at rest. A larger amount of plaster 
than this on the periphery will not carry 
it to certain contact with the peripheral 


the soft tissues of the palate in relation 
to their thickness. It is necessarily lo¬ 
cated in the hamular notches and just 
anteriorly from the vibrating line. It is 
along this line that the tissues will tol¬ 
erate additional pressures. A postdam 
located too far anteriorly will be placed 
on tissues with extreme variation in 
thickness, and if placed too far posteri¬ 
orly will be ineffective because it will be 
in contact with the movable soft palate, 
which, under certain conditions, will rise 
up out of contact with it. 

Stability is attained in this impression 
by the definite contact of the buccal and 
labial flanges with the buccal and labial 



Fig. 3.— Lower plaster wash impression taken in modeling compound tray, used to record 
tissue surfaces of stress-bearing areas at rest and to make vulcanite tray. The landmarks are 
the labial notch (1), buccal notch (2), lingual notch (3), retromolar fossa (4), external 
oblique groove (5), masseter groove (6) and retromylohyoid eminence (7). 


tissues. The flanges of the tray, if too 
high, will interfere with the tissues as 
they are muscle trimmed. The struc¬ 
tures that limit the extent of the den¬ 
ture, such as the labial frenum, buccal 
frenum, buccinator and masseter mus¬ 
cles, and the ramus must have freedom 
for action. The tray must not be too 
large or too small. The peripheral seal 
is maintained at the distal border of 
the denture by means of a postdam. The 
postdam places a uniform pressure on 


surfaces of the alveolar ridge; and by the 
definite contact of the palate with the 
anterior third of the vault and with the 
lingual slopes of the alveolar crest. 

The alveolar ridge is the area which 
furnishes the primary support for the 
denture. However, a hard area in the me¬ 
dian line, the median raphe, must be re¬ 
lieved to make this effective. This is done 
by adding metal to the cast before proc¬ 
essing the denture. The amount of re¬ 
lief to be given to the cast depends on 


67 















the relative hardness of the tissues over 
the alveolar ridge and over the median 
raphe. The extent of the relief depends 
on the size of the hard area. 

The esthetic values are preserved by 
the well-rounded periphery in the an¬ 
terior portion of the impression and its 
thickness, which is regulated according 
to the amount of shrinkage that has oc- 

ALVCOIAR CROOVC 



Fig. 4.—Cross-section through final impres¬ 
sion. The form of alveolar groove is recorded 
in plaster. The remainder of the tissue surface 
is developed in modeling compound. 


face of the mouth, by the thin plaster 
wash. The blood and nerve supply in 
the anterior third of the palate is pro¬ 
tected by extending the relief anteriorly 
to cover the incisive papilla. The blood 
and nerve supply to the posterior two- 
thirds of the palate is adequately pro¬ 
tected by the thick palatal glands which 
cover the greater palatine foramen. 

Adhesion, cohesion and atmospheric 
pressure are all less on the lower denture 
than on the upper, because of the dif¬ 
ference in the area covered by them. All 
of the tissues of the lower jaw, within 
the limits of the functional area, should 
be covered by the lower denture, to de¬ 
velop the maximum effect of these forces. 
(Figs. 3-4.) 

Adhesion and cohesion in the lower 
denture are attained by the accurate 
record of the form of the soft tissues 



Fig. 5.—Landmarks on final lower impression: alveolar groove (1), which is recorded in 
plaster, reproduced in vulcanite tfay and formed in cast; labial notch (2) ; buccal notch (3) ; 
external oblique groove (4) ; masseter groove (5) ; lingual notch (6) ; retromolar fossa (8), and 
retromylohyoid eminences (9). The slopes of the alveolar groove and the entire periphery are 
developed in modeling compound. 


curred and according to the amount of 
support needed by the lips. 

The health of the ridges is provided 
for by a minimum amount of pressure 
applied to the mucous membrane sur- 


when they are at rest. Their form is 
recorded by a thin plaster wash impres¬ 
sion, taken in a modeling compound 
tray. The issues of the crest of the ridge 
are not distorted by a resistant impres- 


68 










sion material. A cast is formed in this 
impression, and a vulcanite tray is proc¬ 
essed over this cast. The bottom of the 
alveolar groove in the vulcanite tray has 
the same form as the plaster wash im¬ 
pression. This form is carried through 
to the completed denture. The periph¬ 
ery of the tray is cut until it is i mm. 
short of the reflected tissues. Also, 0.5 
mm. and all undercuts are removed from 



Fig. 6.—Anatomy of lower jaw. For reten¬ 
tion, the denture makes continuous contact 
with structures that limit it: the labial frenum, 
buccinator muscle (1), masseter muscle (2), 
anterior border of ramus, temporal tendon 
(7), retromylohyoid curtain (5) and superior 
constrictor muscle, which is backed up by 
internal pterygoid muscle (3), mylohyoid 
muscle (9) and lingual frenum. The lingual 
flange lies between the alveolar ridge and the 
sublingual fold (10), the lingual nerve (8) 
and the anterior tonsillar pillar (4). The den¬ 
ture must cover the retromolar pad (6). 
Stability is attained by contact with the slopes 
of the alveolar ridge. Support is given by the 
alveolar ridge and the buccal shelf medially 
from the external oblique line. The appear¬ 
ance is improved by supporting the lip. The 
health of the ridge is preserved by limiting 
pressure on the crest of the ridge, placing the 
heaviest pressure on the buccal shelf. 


the slopes of the alveolar groove in the 
tray. 

Modeling compound is added to the 
cut surfaces of the tray to restore the 
contact with the slopes of the ridges, and 
to perfect the peripheral seal. This 
compound is heated and inserted in the 
mouth in such a way that the excess 
will flow over the crest of the ridge and 
out over the periphery. When it is re¬ 
moved from the mouth, the compound 
that has moved down into the bottom 
of the alveolar groove on to the uncut 
vulcanite is removed. This process is 
repeated until no compound moves into 
the bottom of the alveolar groove, and 



Fig. 7.—Suctorial pad (indicated by arrow) 
in cheek, which folds over distal-buccal angle 
of denture to make perfect peripheral seal, 
and automatic soft tissue lock on lower den¬ 
ture in that area. 

until the junction between the uncut 
vulcanite and the compound is smooth, 
with no ledge either way. This restores 
the form of the slopes of the alveolar 
groove and controls the amount of pres¬ 
sure upon it. (Figs. 5-6.) 

Atmospheric pressure is effective as a 
retentive force because of the peripheral 
seal developed by the muscle trimming 
in modeling compound. The seal is de¬ 
veloped as a plastic record of the struc¬ 
tures that limit the extent of the im¬ 
pression. These structures are the labial 
frenum, the reflected labial mucous 
membrane, the buccal frenum, the buc¬ 
cinator muscle and reflected area of the 


69 


f 




















cheek, on the labial and buccal aspect; 
the masseter muscle, the anterior border 
of the ramus, the pterygomandibular 
raphe, the superior constrictor of the 
pharnyx and the retromylohyoid cur¬ 
tain, on the distal aspect; the mylohyoid 
muscle, the soft tissues in the floor of 
the mouth and the lingual frenum on 
the lingual aspect. The controlled plas¬ 
ticity of the modeling compound makes 
it possible to vary the amount of ten¬ 
sion on each of these structures. There 
are a few areas which require special 
attention. The masseter muscle and the 
internal pterygoid muscle are brought 
into approximation with the impression 
only when under contraction. Therefore, 
a downward pressure should be exerted 
on the impression tray in muscle 
trimming these areas. The mylohyoid 
muscle and the tissues supported above 
it vary greatly in their form and posi¬ 
tion with different tongue positions. The 
lingual flange must be extended down¬ 
ward far enough to maintain a continual 
contact with the floor of the mouth un¬ 
der all conditions. Also, the lingual, 
flange of the denture must slope toward 
the tongue at such an angle that these 
structures will be free to move into all 
positions. The floor of the mouth in the 
region from bicuspid to bicuspid is rela¬ 
tively closer to the cast of the ridge than 
it is posteriorly from that point. The 
lingual flange in this region must main¬ 
tain a continual contact with the floor 
of the mouth without limiting the action 
of the tongue. It must be possible for 
the patient to protrude the tongue far 
enough to wet the lips without inter¬ 
ference. The suctorial pad in the cheek 
folds over the distobuccal angle of the 
denture. (Fig. 7.) 

Stability against forces tending to 
move the denture horizontally is at¬ 
tained by the modeling compound record 
of the slopes of the alveolar ridge. Mod¬ 
eling compound heated to 135 degrees 
is less plastic than plaster of Paris. The 
modeling compound will, therefore, exert 


a slightly greater pressure on the slope of 
the ridge than the plaster. This will 
assure a definite resistance to horizontal 
forces applied to the denture. The area 
lingually from the bicuspids is particu¬ 
larly effective in this respect. It is an¬ 
teriorly from the sharp mylohyoid ridge 
and therefore can be made to fit the 
mandible very closely. 

The most favorable areas for support 
of the denture are on the crest of the 
alveolar ridge and on the buccal shelf. 
The crest of the ridge is cushioned by 
soft tissue, which is not displaced or 
distorted by the impression and which is 
completely at rest when no pressure is 
being exerted upon the denture. The 
buccal shelf, the area between the crest 
of the ridge and the external oblique 
line, consists of smooth cortical bone and 
is covered by the attachment of the 
buccinator muscle. It is nearly horizon¬ 
tal except at its anterior end. It is one 
of the most nearly ideal surfaces in the 
lower jaw that can be used for the 
support of a denture. The modeling 
compound record of this form is de¬ 
veloped in such a way as to place the 
heavy masticatory load on this surface. 
This area carries more of the pressure 
than does the crest of the alveolar 
ridge. 

The form and thickness of the labial 
flange of the lower denture affect the 
appearance in the same way as in the 
upper. 

The conditions that tend to preserve 
the lower ridge and maintain its health 
are related to the preceding objectives. 
The tissues on the crest of the ridge are 
protected by their automatic relief. The 
plaster impression that determines their 
form is taken while they are at rest. 
The modeling compound on the slopes 
of the ridges relieves the pressure on 
the tissues of the crest. The heavier 
pressure is transmitted first to the buccal 
shelf, which is ideally situated to resist 
these forces. The denture is stable and 
therefore horizontal movement is re- 


70 


duced to a minimum. Horizontal move¬ 
ment causes much of the destruction of 
ridges. The compound on the slope of 
the ridges is handled in such a way 
that it cannot cause a gripping of the 
ridge. It must be heated to a tempera¬ 
ture that will cause it to exert more 
pressure than plaster of Paris, but not 
enough to form a ledge on the inside of 
the denture. If this surface is formed in 
such a way as to cause no ledge to ap¬ 
pear on the slope of the denture, the 
pressure is properly balanced between 
the crest and the slope. This develops 
the most favorable protection for the 
blood and nerve supply to the tissues, 
and facilitates repair of damage done 
by the denture. 

It is obvious that there are factors 


other than impressions in successful den¬ 
ture construction. Occlusion, arch form, 
leverages, tooth color, size and form are 
a few of the varied problems that af¬ 
fect the retention, stability, support and 
appearance of the denture, and the pres¬ 
ervation of the alveolar ridge. Each step 
in the construction of complete dentures 
has its own responsibility for the end- 
results. Good impressions are necessary 
to success because all the other prob¬ 
lems are dependent on their success for 
their solution. 

BIBLIOGRAPHY 

Edwards, L. F., and Boucher, G. O.: An¬ 
atomy of Mouth in Relation to Complete 
Dentures. J.A.D.A., 29:331-345, March 1942. 

Boucher, C. O.: Impressions for Complete 
Dentures. J.A.D.A., 30 :14-25, January 1, 1943. 





A PRELIMINARY REPORT ON PENICILLIN IN DENTISTRY 

LEO STERN, D.D.S. 1 


Penicillin has already produced an impressive literature, but it has yet to be 
evaluated in the treatment of diseases of the mouth. As it may soon be available 
to the profession, it seems desirable to describe some personal observations deal¬ 
ing with its use in dentistry. 

Penicillin has properties that offer many advantages over the sulfonamides in 
the direction of range and potency. These were recently described from the 
point of view of the bacteriologist by Bartels ( 1 ) Interpreted in clinical terms of 
dental interest they may be restated as follows: 

1. Its high solubility in water indicates the probability of increased local 
effectiveness by rapid absorption into underlying tissues. Conversely, this 
quality carries the disadvantage of requiring more frequent application to open 
surfaces such as are encountered in lesions of the mouth, where it may be washed 
away too quickly. For such cases a relatively insoluble and tenacious base is 
indicated. However, absorption is not too rapid when it is injected into closed 
cavities such as root-canals, infected cysts and suppurating sinuses. The agent 
itself is non-irritating. 

2 . Penicillin is bacteriostatic in high dilution towards many, but not all strains 
of staphylococcus aureus. Lower dilutions appear to influence streptococcus 
viridans recovered from cases of subacute* bacterial endocarditis (2). Reported 
cures of this disease ( 3 ) should be accepted with extreme reserve at this time, but 
it seems beyond question that penicillin is able to eliminate those organisms that 
are freely floating in the bloodstream. This quality may prove of value in the 
treatment of dental periapical infections. 

3 . Because the potency of penicillin is not inhibited by peptone, tissue secre¬ 
tions or pus, as are the sulfonamides, it is useful in such dental lesions in which 
pus has formed, as abscess cavities and osteomyelitis. 

4 . Penicillin is more effective in the treatment of chronic infections than the 
sulfonamides. 

5 . When properly diluted with pyrogen-free distilled water the more recent 
samples exert no toxic effects on blood cells, excretory organs, or on tissue to 
which it may be applied locally ( 4 ). 

This report deals with the application of penicillin in fusospiral gingivitis, 
putrescent root-canals, and in one case of severe post-extraction infection. The 
number of cases in this series is far too small to justify the drawing of conclusions, 
but a brief statement of methods and findings may be of assistance to others when 
the agent becomes generally available. 

FUSOSPIRAL GINGIVITIS 

The preparation used in this series was a cream-cellulose-base, soluble in 
water 1:12, containing penicillin to the value of 250 Florey units pei cubic centi- 

1 Dental Department, Mt. Sinai Hospital, N. Y. 


72 


meter. Six patients were treated, each with the typical history and symptoma¬ 
tology of fusospiral gingivitis. The onset was sudden, ushered in by sore and 
bleeding gums, and a moderate degree of malaise. There was a putrid odor to the 
breath, hypersalivation, frank gingivitis with necrotic ulcers, and lymphadenitis. 
Blood counts were normal in four patients; one showed a leucocytosis ( 13,500 
w.b.c. per mm.); and in another, there was a slight qualitative anemia with occa¬ 
sional abnormally large red cells. A profusion of fusospirochetes was demon¬ 
strated in the smears. Each patient was given a small quantity of the prepara¬ 
tion and instructed to apply it to the gums every three hours. Nothing was to 
be taken by mouth for an hour afterward, and no supplemental treatment was 
prescribed. Results are summarized in Table I. 

Cases 1 and 4 responded extremely favorably. After two days, although 
smears were still positive, bleeding was almost completely controlled, many 
ulcers had resolved, lymphadenitis was reduced and the patients stated that they 
felt much better. After four days, clinical improvement seemed complete in 
both patients and routine periodontal treatment was substituted. 


TABLE I 


CASE NO. 

BLOOD COUNT 

GINGIVAE, 

2nd DAY 

4th day 

6th day 

1 

Normal 

+ 

++ 

-f- + 

2 

Qualitative anemia 

— 

+ 

+ 4 - 

3 

Normal 

— 

— 

— 

4 

Normal 

+ 

++ 

++ 

5 

Leucocytosis 

— 

— 

— 

6 

Normal 

— 

— 

— 


—, indicates no change; +, improvement ; -f+ , marked improvement. 


This course was paralleled in Case 3 after the fourth day. No improvement 
was noted after six days in Cases 5 and 6: thereafter the patients were treated in 
the routine manner with good results. It seems a conservative comment that if 
fusospiral gingivitis is a local infection, some strains of the exciting organisms 
appear to be influenced by penicillin. Unfortunately the fusospirochetes cannot 
be cultured as a group and as yet no “in vitro” method is available for testing 
their sensitivity. 

THERAPY OF PUTRESCENT ROOT-CANALS 

The preparation used was penicillin dissolved in distilled water to the value of 
250 units per cubic centimeter. Five patients were selected for this experiment, 
each complaining of subactute pericementitis in an anterior tooth, associated 
with loss of viability and a putrid odor to the pulp. The following criteria were 
used in selecting cases: sudden onset of severe pain, marked tenderness to percus¬ 
sion, and negative response of the affected tooth to the karadic current. In each 
case distinctly putrescent pulps were uncovered and preliminary cultures were 
made after isolating the tooth, gaining access to the pulp chamber, and removing 


73 













the coronal half of pulp debris. Penicillin was injected into the canal, using a 
Luer syringe to which was attached a silver lachrymal needle having a wrapping 
of rubber dam to serve as a washer. The degree of pressure employed in the in¬ 
jection was just sufficient to ellicit a pain response. Cavities were sealed with 
gutta-percha. The results of cultures during the course of treatment are given 
in Table II. 

At the second visit each patient gave a story of early relief from pain with 
gradually receding tenderness. Cultures were negative in two cases after three 
days, and remained so on the sixth and twelfth day, when the root-canals were 
filled with Callahan’s resin solution and gutta-percha points. Another patient 
responded in like manner on the sixth day. In Cases 2 and 5 there was seepage 
present in the canals after twelve days and a persistent moderate tenderness. 
The apices of these teeth were resected and the root-canals filled; the periapical 
tissues appeared normal. 


TABLE II 

Putrescent canals treated with penicillin 


NO. 

TOOTH 

CULTURE 

CULTURE 

3rd DAY 

CULTURE 

6th DAY 

CULTURE 

12th day 

1 

UL 2 

Str. Viridans 

+ 

— 

— 

2 

UR 3 

Str. Viridans 

Staph. Albus 

+ 

+ 

+ 

3 

UR 5 

Staph. Aureus 

— 

— 

— 

4 

UL2 

Str. Viridans 

— 

— 

— 

5 

ULl 

Str. Viridans 

Staph. Aureus 

+ 

+ 

+ 


Although the results of these experiments were equivocal, penicillin appeared 
to be effective in three cases. It remains to be demonstrated in a large series 
whether it will prove superior to currently used agents. 

POST-EXTRACTION INFECTION 

On March 14 th, M. W., a 28 year old housewife, previously in good health, complained of 
pain and swelling on the left side of the jaw and neck. Four days earlier, an unerupted 3 rd 
molar had been removed under local anesthesia. Reaction was not severe until the third 
day, when a shaking chill was experienced in the morning, followed by a rise of temperature 
to 102 .2°F. The tissues of the neck and over the jaw began to swell considerably and there 
was severe pain in the jaw, radiating to the ear. Another brief chill occurred the next morn¬ 
ing, followed by a fever of 103 °F. 

The patient appeared acutely ill. The skin covering the mandible and submaxillary area 
was red and diffusely swollen, exquisitely tender to pressure, but not fluctuant. Trismus 
was noted and the floor of the mouth on the left side was somewhat edematous and tender. 
A gauze dressing removed from the socket of the 3 rd molar was stained and had a foul odor. 
No other significant clinical signs were found. A blood culture and complete count were 
ordered, a boric acid dressing applied externally, and intra-oral irrigations of hot saline 
solution prescribed, together with aspirin and codein for sedation. 

There was no improvement nor did a fluctuant point develop during the next two days. 
The temperature rose to 103 . 4 °F. The blood picture was normal excepting for a white cell 


74 
















count of 12,000, but the blood culture showed many colonies of staphylococcus aureus. The 
laboratory reported (his strain to be sensitive to 5 units of penicillin. 

1 reatment with penicillin was begun on March 16th at 5 p.m., with 10,000 units injected 
intramuscularly every 4 hours. The following day the maximum temperature was 100.8°F. 
and the patient felt decidedly better. On March 18th the temperature remained below 
100°F, the external swelling was considerably reduced and the edema in the floor of the 
mouth had resolved. Therapy was discontinued after 120,000 units had been injected. 
r i here was no evidence of spontaneous discharge of pus and the patient made an uneventful 
recovery. A follow up examination on April 3rd showed a nicely granulating socket, with 
neither tenderness nor swelling externally. 

COMMENTS 

Taken individually, none of these cases followed a pattern of improvement that 
is not often observed with other forms of therapy. However, the percentage of 
favorable responses suggests therapeutic benefits at least equal to that of cur¬ 
rently approved agents. A considerably larger number of dental case reports 
covered by adequate clinical and laboratory controls must be accumulated before 
the value of penicillin can be measured. 

It seems reasonable to conclude, however, that considerable variation exists 
in the sensitiveness to penicillin among the many strains of organisms found in 
dental infections. Fortunately a convenient laboratory technic is available for 
measuring this quality. It is recommended that this method be used as an “in 
vitro” control to clinical experiments. 

7 

BIBLIOGRAPHY 

1. Bartels, H. A.: Antibacterial Substances Obtained from Micro-organisms, Ann. of 

Dent., 2: 145, 1944. 

2. Loewe, L., Rosenblatt, P., Green, H. J. and Russell, M.: Combined Penicillin and 

Heparin Therapy of Subacute Bacterial Endocarditis, J. A. M. A., 124: 144, (Jan. 15) 
1944. 

3 . Keefer, C. S., Blake, F. G., Marshall, E. K., Jr., Lockwood, J. S., and Wood, W. B., 

Jr., Penicillin in the Treatment of Infections: Report of 500 Cases, J. A. M. A., 122: 
1217 (Aug. 28) 1943. 

4 . Penicillin: Its Action and Uses, Merck and Co., Rahway, N. J., 1944. 



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75 






ROOT-CANAL THERAPY AND THE USE OF 

SULFONAMIDES 


Norman Rosen, D.M.D., New York, N. Y. 


# 


I N root-canal therapy, we have to 
contend with an infectious condition 
of the pulp caused by the invasion 
of either staphylococci or streptococci, 
or both. In 1935, Domagk demonstrated 
that mice could be protected against 
fatal doses of streptococci with pron- 
tosil. 1 This discovery was the forerunner 
of the use of the sulfonamide group of 
drugs, and a new weapon had been 
evolved to combat infection from these 
organisms. 

The mode of action of sulfonamides 
is thought to be primarily bacteriostasis. 
Long and Bliss, in 1936, found that the 
drug acted directly on the bacteria, de¬ 
stroying the capsules of these micro¬ 
organisms and rendering them more 
susceptible to destruction in this aviru- 
lent state by the defense mechanism of 
the individual. 2 It has been observed 
further by Lockwood 3 that any product 
of protein digestion, such as is found in 
a necrotic area, will inhibit this bacterio¬ 
static activity of the sulfonamides. This 
action is explained by the close similarity 
of the chemical structure of the drugs 
of this group and that of para-aminoben- 
‘zoic acid, a product of protein hydrolysis. 
One competes with the other in bacterio- 
metabolism. 4 This fact is very important, 
as it tells us that, before an infection is 
ready for chemotherapy, all necrotic ma¬ 
terial and debris must be removed. This 
precaution is as necessary in root-canal 
therapy as it is in any other form of 
surgical procedure. 

In dentistry, the sulfonamides com¬ 
monly used are sulfanilamide, sulfathia- 
zole and sulfadiazene. In root-canal 
therapy, we are concerned with the 


same drugs. The specific action of these 
drugs on certain organisms has been de¬ 
termined, 2 ’ 5 * 6 ’ 7 ’ 8 and it is advisable to 
choose the drug on the basis of the or¬ 
ganism present. This effect has been in¬ 
terpreted by the reaction of the drug and 
the enzyme secreted by the bacteria. The 
enzyme of one type of bacteria may be 
interfered with by one of the sulfona¬ 
mides, while that of another remains un¬ 
affected. 

When to use the drug, and which one 
to use, therefore depends on the type of 
infection present. Sulfanilamide has 
been found to be more efficacious against 
streptococcic infections; sulfathiazole 
against staphylococcic infections, and 
sulfadiazene against mixed infections, 
especially in the presence of Streptococ¬ 
cus viridans. From these facts, we may 
deduce that for an acutely abscessed and 
purulent pulp, the staphylococcus being 
the chief offender, we should employ sul¬ 
fathiazole. Chronic abscesses, such as are 
seen with granulomas, generally reveal a 
streptococcus infection in which the use 
of sulfanilamide would be more effica¬ 
cious. Sulfadiazene, being used where 
mixed infections are present, may be ap¬ 
plied in either case. It is permissible, 
however, to interchange these drugs in 
some instances, since the line of bacterio¬ 
static action is not definitely drawn. 

The sodium salts of these drugs have 
a high degree of alkalinity, the pH rang¬ 
ing from 9 to 11. They are, therefore, 
extremely irritating and should not be 
used. When in saturated solutions, they 
have been known to coagulate human 
serum. 6 ’ 10 

The bacteriostatic and the bactericidal 







properties of the sulfonamides have been 
demonstrated by many investigators. 
Adams 11 states that “the hot sulfanila¬ 
mide solution is bacteriostatic after 60 
seconds’ contact with the growth, but 
continued contact with the drug after 
the first immersion is bactericidal.” 
Other investigators, such as Goodman 
and Gilman, 12 have shown this effect in 
vitro and reached the same conclusion 
when they applied the drug to open 
wounds or infections. 

The local application of the sulfona¬ 
mides, although it had come into use 


the treatment of wounds by adequate 
early cleansing followed by debridement 
and dusting into the wound of a suffi¬ 
cient quantity of sulfanilamide or sulfa- 
thiazole. McGehee 15 has reported a 
series of 407 cases of perforated appen¬ 
dix wherein sulfanilamide was employed 
locally with a mortality of 6.2 per cent. 
Previously, in a control series, the mor¬ 
tality had been 41.5 per cent. It has 
been further observed that local applica¬ 
tion in wounds may produce as much as 
from 10 to 20 times higher concentration 
of the drug in the area than can be 



A B 

Fig. 1.—Case in man aged 35. The patient complained of a dull ache in the area. A, appear¬ 
ance in February 1941 ; showing improper treatment rendered a number of years ago in Greece. 
B, tooth properly treated and filled. The symptoms have subsided. 



A B 

Fig. 2 . —Case in woman aged 43. A, appearance November 1939 ; showing faulty treatment. 
The patient complained of sensitivity of the tooth. B, condition after root-canal therapy had 
been repeated. 


after the method of oral administration, 
has shown outstanding results. In the 
military field, this has been taken ad¬ 
vantage of to the extent that every 
American soldier who goes into action 
is provided with 5 sulfanilamide 

powder, which is to be implanted im¬ 
mediately in any wound. 13 Moorhead, 14 
in reporting an extensive military experi¬ 
ence following the Pearl Harbor disaster, 
stated that he obtained good results in 


obtained by systemic administration. 
This high has been as much as 500 mg. 
per hundred cubic centimeters of local 
tissue fluid with a blood level high of 
approximately 2 mg. per hundred cubic 
centimeters, a quantity well under the 
level of toxicity. 2 The quantity of sul¬ 
fonamides used in root-canal therapy is 
even smaller and their local application 
is, therefore, not great enough to affect 
any systemic disorders. 



) 



















There has been considerable discussion 
of the efficacy of the local use of sulfon¬ 
amides in the mouth after extractions. 
The results may be questioned by the 
fact that the drug, incorporated by the 
tissue fluid of the wound, is constantly 
exposed to the action of saliva and the 
contamination of the mouth. In surgical 
procedures involving a closed cavity, as 
in abdominal operations, as well as root- 
canal therapy, outside contamination 
does not exist and the action of the sul¬ 
fonamides is left unimpaired. 

From the foregoing facts, it can be 
seen that I have given a brief resume of 
the basis for the use of the sulfonamides 
in root-canal therapy. At this point, I 
shall describe my method and use of 
these drugs and certain principles that 



A B 

Fig. 3.—Case in girl aged 13. The pulp of 
the tooth had become acutely abscessed as the 
result of a blow. A, condition March 1941 be¬ 
fore treatment; B, October 1941. The tooth 
had been rendered comfortable soon after 
treatment, which was completed in six visits. 
Orthodontic treatment was instituted soon 
after. 

I adhere to in treatment. To begin with, 
chemotherapy is just part of a technic 
of root-canal treatment. It is necessary 
to supplement this at the outset with 
proper and sterile instrumentation as 
well as to complete the treatment with 
the correct filling of the canal. Figures 1 
and 2 illustrate cases of which one might 
say that failure in root-canal work was 
due to a faulty method of therapy in 
more than one phase. In both instances, 


subjective symptoms of discomfort were 
called to my attention by the patient, 
and disappeared after proper treatment 
and root-canal filling. 

I use the sulfonamides (1) whenever 
infection of the pulp or periapical area 
is suspected and (2) only when these 
drugs can be applied so as to come in 
contact with tissue fluid. 

Vital pulps obviously do not need 
comparable chemotherapy 5 therefore, 
these drugs are unnecessary. If there is 
pulp degeneration, with a loss of the 
germicidal blood supply, or infection has 
progressed beyond the apex, I utilize the 
aid of the sulfonamides to eliminate in¬ 
fection and so assist the body in its work 
of repair. 

The sulfonamides when in contact 



A B 

Fig. 4.—Case in boy aged 19. The tooth 
had become abscessed as the result of carious 
exposure. Treatment was completed in five 
visits. A, condition November 1941, before 
treatment; B, April 1942. 

with tissue fluid are readily absorbed. 
The method of use of these drugs is 
therefore based on this principle. Be¬ 
cause of their high degree of diffusibility, 
they may, through absorption, attain a 
wide area of distribution in the body. 16 
In root-canal therapy, the drugs are ap¬ 
plied, therefore, in a manner to make 
contact with tissue fluid, in order to 
cause absorption. 

Sulfanilamide and sulfadiazene are 
used in solution form as irrigants. Sulfa- 
thiazole, although more difficult to ob¬ 
tain in solution, is applied as a powder 







or made into a paste with glycerin and 
mixed with the purulent exudate in the 
canal of a tooth. In this form, it may 
be used as a dressing. Sulfanilamide, 
having the greatest solubility of the 
group, is dissolved in sterile water or 
saline solution. Although it is soluble to 
the extent of 1.46 per cent in water at 
body temperature, 17 solubility is in¬ 
creased to more than 6 per cent at 6o° 
C. (140 F.), 18 at which temperature it 
is applied. The use of a warm solution 
enhances the bactericidal action. When 
it is injected locally, 1.97 per cent will 
be soluble in human serum at body tem¬ 
perature. 17 

Sulfadiazene, like sulfathiazole, has a 
low solubility, but recently has been com- 



A B 

Fig. 5.—Case in woman aged 56 A trau¬ 
matic abscess developed, with acute symp¬ 
toms. A, condition November 1941; B, July 
1942. Treatment called for six visits. 

pounded in a solution of 2.5 per cent 
sulfadiazene in 8 per cent triethanol¬ 
amine. This mixture has a pH of about 
8.7, is not toxic and is readily absorbed 
by the tissue. Its use has been deter¬ 
mined by a group of investigators 19 ’ 20 
from the Department of Otolaryngology 
at the Johns Hopkins University and 
Hospital and found successful in con¬ 
trolling the growth of pyogenic organ¬ 
isms in the upper air passages, with a 
marked decrease in the incidence of 
sinus, ear, pharynx and bronchial infec¬ 
tions. Their deduction was that, al¬ 
though these areas were not sterilized, 
the clinical results suggest that certain 


strains of bacteria react in such a way as 
to lose their virulence or their ability to 
become virulent. Since the type of tissue 
involved in such infections is similar to 
those tissues in the root canal, the mix¬ 
ture can be similarly used for such treat¬ 
ment. I have applied it to the canal as 
sulfanilamide is applied, as an irrigant, 
after the solution has been heated. 

If the sulfonamides are used in the 
sterile crystalline form, there will be lit¬ 
tle, if any, interference with the healing 
process. Since the primary aim in any 
treatment is to permit Nature to set up 
her healing mechanism quickly, by con¬ 
trolling infection with a sulfonamide we 
obtain this objective. This fact has been 
substantiated by many investigators, 



A B 

Fig. 6.—Case in woman aged 32. The pa¬ 
tient was referred for root-canal therapy after 
a prolonged attempt at treatment by another 
dentist. The symptoms had become acute. 
A, condition February 1943; B, June 1943. 
Six visits were necessary. 

among them Colebrook, Francis, 21 Taf- 
fel, Harvey 22 and others. 23 

Bacteriologic examination will deter¬ 
mine primarily when a canal is ready for 
filling. For this purpose, a culture of a 
medium of glucose-ascites broth or 
brain-heart infusion broth, or the like, 
may be used; or the findings may be 
determined by a smear through micro¬ 
scopic examination. For accuracy, the 
culture is the more precise method. 
However, although the bacteriologic ex¬ 
amination of root canals will serve as a 
valuable guide, as well as lead the oper- 


79 











ator to preserve a sterile technic, it is still 
debatable whether absolute sterility is pos¬ 
sible or necessary before a canal may be 
filled. As Cahn 24 states : “Surgeons do not 
wait for negative cultures until they close 
a wound. If they did, most patients after 
a laparotomy would be lying around with 
their entrails hanging out.” 

If the total number of bacteria can 
be reduced or even kept constant, the 
white blood cells can be relied on to 
eliminate them. The trouble is that bac¬ 
teria multiply exceedingly fast, it having 
been estimated that under proper condi¬ 
tions a single bacterium produces one 
billion descendants in fifteen hours; 
hence, the need for such deterrent agents 
as the sulfonamides. In the past, I have 
used the culture method at the start of 



A B 

Fig. 7.—Case in boy aged 13. An acute 
abscess developed from a blow. The patient 
was having orthodontic care at the time. A, 
condition November 1942; B, April 1943. 
Treatment called for six visits, after which 
orthodontic treatment was resumed. 

chemotherapy with the sulfonamides 
mainly to determine the time of treat¬ 
ment. At present, I have discontinued 
the use of cultures, but still resort to 
smears as a guide to therapy. I have 
found the average number of visits in 
most cases to be five or six. Adams re¬ 
ports that the average for fifty-two cases 
is 3.18 treatments. 25 

I had previously confined my treat¬ 
ment in root-canal therapy to the ortho¬ 
dox medicaments, namely eugenol, 
beechwood creosote, cresatin and tri- 


formocreosol, using as well electrosterili¬ 
zation. By this method alone, I found 
that purulent and acutely infected 
teeth required a dozen or more treat¬ 
ments before a negative culture or smear 
could be obtained. Since the use of sul¬ 
fonamides, the number of such treat¬ 
ments in practically all cases has been 
reduced at least half. I still, however, 
use the above-mentioned drugs in con¬ 
junction with sulfonamide therapy be¬ 
cause of tissue tolerance of repetitious 
application of the same drugs, and be¬ 
cause some of these conventional drugs 
assist in thp elimination of the products 
of protein hydrolysis, thereby enhancing 
the action of the sulfonamides. 

The accompanying roentgenograms 
show examples of results of the method 
of root canal treatment just described. 
Figures 3 to 7 indicate the condition of 
teeth before treatment and the results of 
healing processes as shown by these teeth 
in roentgenograms taken approximately 
six months later. 

The use of sulfonamides may be fur¬ 
ther superseded by the newer develop¬ 
ments of such bactericides as gramicidin 
and penicillin. Gramicidin was obtained 
from soil bacteria in 1939 by Rene 
Dubos, of the Rockefeller Institute of 
Medical Research. Although it is highly 
insoluble, its use after operative pro¬ 
cedures locally has greatly lessened post¬ 
operative complications and discomfort. 
As its name implies, it is bactericidal pri¬ 
marily against gram-positive organisms. 26 
Penicillin, the byproduct of a fungus, 
Penicillium notatum, was discovered by 
Alexander Fleming, an English bacteri¬ 
ologist, in 1928. This drug has added 
advantages in that it is soluble and there¬ 
fore may penetrate tissue to a greater 
extent, with the further advantage of 
being neither toxic nor irritating. It is 
exceedingly effective in combating 
staphylococcic infections and is equally 
effective against the aerobic and the 
anaerobic streptococcus and the pneumo¬ 
coccus. 27 Neither of the drugs, however, 


80 













has been marketed, although indications 
are that they may be released in the near 
future. It is hoped that their applica¬ 
tion will meet with similar success in 
root-canal therapy, as well as in other 
fields of dentistry. 

CONCLUSIONS 

From a theoretical, experimental and 
clinical point of view, it is rational to 
conclude that in root-canal therapy the 
sulfonamides aid in eliminating infec¬ 
tion. 

In root-canal therapy, these drugs 
must be employed with two important 
facts in mind: i. They may be used only 
in direct contact with tissue fluid through 
irrigation or by mixture of the powder, 
such as sulfathiazole, with tissue fluid in 
the canal of the tooth. 2. They are used 
only when infection of the pulp exists 
and especially when the infection has 
progressed to the periapical region. 

Chemotherapy with the sulfonamides 
alone is not a panacea in root-canal 
therapy, but must be supplemented by an 
aseptic root canal technic. 

Gramicidin and penicillin may prove 
even more effective substitutes for the 
sulfonamides as bacteriostatic agents. 
Their use in root-canal therapy remains 
to be developed. 

BIBLIOGRAPHY 

1. Spink, W. W.: Sulfanilamide and Re¬ 
lated Compounds in General Practice. Chi¬ 
cago: Year Book Publishers, Inc., 1943. 

2. Rosen, Norman: Use of Sulfonamides 
in Root Canal Therapy. N. Y. J. Dent., 13 : 
143, April 1943. 

3. Lockwood, J. S.: Surgery, 10:493, Sep¬ 
tember 1941. 

4. Rosamilia, P. A.: Sulfonamide Therapy 
in Dentistry: A Review. J.A.D.A., 30:1707, 
November 1,. 1943. 


5. Ostrander, F. D.: Sulfonamides in Den¬ 
tistry. J.A.D.A., 30:1830, December 1, 1943. 

6. Reference 4, p. 1708. 

7. Report of Committees on Chemothera¬ 
peutic and Other Agents, and Surgery of Di¬ 
vision of Medical Sciences of National Re¬ 
search Council. War Med., 2:488, May 1942. 

8. Local Use of Sulfonamides. Bull. Lederle 
Lab., 10:7i, December 1942. 

9. Reference 5, p. 1833. 

10. Adams, F. R.: Hot Solutions of Sulfon¬ 
amides. J.A.D.A., 30:59, January 1, 1943. 

11. Reference 10, p. 67. 

12. Goodman, L. G., and Gilman, Alfred: 
Pharmacological Basis of Therapeutics. New 
York: Macmillan Company, 1941, chaps. 56 
to 59 - 

13. Medicine and War. J.A.M.A., 119 : 
1029, July 25, 1942. 

14. Moorhead, J. J.: J.A.M.A., 118:712, 
February 28, 1942. 

15. McGehee, J. L.: Mississippi Doctor. 
18:488, February 1941. 

16. Kayne, C. B.: Sulfanilamide Therapy 
Pertaining to Dentistry. J.A.D.A., 28:105, 
January 1941. 

17. Reference 5, p. 1833. 

18. Reference 10, p. 63. 

19. Bordley, J. E., et al .: Local Use of 
Sulfonamides, Gramicidin and Penicillin in 
Otolaryngology. Ann. Otol., Rhin. & Laryn.j 
51:936, December 1942. 

20. Dolowitz, D. A., et al.: Prevention of 
Ear and Nasal Sinus Complications of Com¬ 
mon Cold. J.A.M.A., 123:534, October 30, 
1943 - 

21. Colebrook, L., and Francis, A. E.: 
Lancet, 1:271, March 1, 1941. 

22. Taffel, M., and Harvey, S. C.: Proc. 
Soc. Exper. & Biol. Med., 45:647, November 
1940. 

23. Stein, H. A.: Prophylactic Value of 
Sulfonamides in Traumatic Dental Surgery. 
J.A.D.A., 30:1922, December 1, 1943. 

24. Cahn, L. R.: Study of Periapical Path¬ 

ology: Its Influence on Pulp Canal Therapy. 
N. Y. J. Dent., 12:329, October 1942. 

25. Reference 10, p. 61. 

26. Reference 19, p. 940. 

27. Reference 19, p. 944. 

981 Madison Avenue. 



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